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Irpartmrnt  of  ^ttrgprg 
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WORKS  BY  MR.  B.  G.  A.  MOYNIHAN 


Retroperitoneal  Hernia.     London,  1899 
Bailliere,  Tindall  &  Cox 

The  Sargical  Treatment  of  Gastric  and  Duodenal 
Ulcers.  W.  B.  Saunders  &  Co.,  1903 

Gafl-Stones  and  their  Surgical  Treatment 
Second  Edition,  1905  W.  B.  Saunders  &  Co. 

Abdominal  Operations 
Second  Edition,  1906  W.  B.  Saunders  Company 

Duodenal  Ulcer*         W.  B.  Saunders  Company,  19 10 

Pathology  of  the  Living  and  other  Essays.     W.   B, 

Saunders  Company,  1910 


WITH    MR.    MAYO    ROBSON 

Diseases  of  the  Stomach.  Second  Edition,  1905 

Diseases  of  the  Pancreas.     W.   B.  Saunders  &  Co. 

1902 


THE 

PATHOLOGYo/zAe  LIVING 

AND  OTHER  ESSAYS 


BY 

B.  G.  A.  MOYNIHAN.  M.S.  (Lond.).  F.R.C.S. 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1910 


Copyright,  1910.  by  W.  B.  Saunders  Company. 


PRINTED      IN      AMERICA 


Preface. 

In  this  volume  are  included  a  number  of  essays  which 
have  appeared  in  various  medical  journals  during  the 
last  few  years.  Their  republication  in  this  form  has 
been  sanctioned  at  the  request  of  many  of  my  friends. 
I  should  perhaps  have  been  a  little  diffident  about  the 
wisdom  of  this  course  if  I  did  not  feel  that,  however 
imperfectly,  some  of  these  papers  present  a  fresh,  per- 
haps even  a  new,  view  of  many  of  the  problems  which 
are  at  present  engaging  the  attention  of  the  surgeon. 

The  time  has  come,  I  think,  when  the  surgeon  must 
cast  off  some  of  the  shackles  by  which  he  has  been 
fettered  for  so  many  years.  When  research  into  the 
conditions  within  the  abdomen  has  been  conducted 
during  the  course  of  an  operation,  the  fruits  have  been 
judged  by  the  standard  set  up  by  the  disclosures  and 
by  the  statistics  of  the  post-mortem  room.  Differences 
often  of  the  gravest  significance  between  the  evidence 
offered  by  the  two  modes  of  investigation  have  not 
been  co-ordinated,  or  even  compared;  they  have  been 
contrasted  to  the  detraction  and  the  detriment  of  the 

5 


PREFACE. 


surgeon's  work.  His  enquiry  has  been  reckoned  as 
valueless  in  so  far  as  it  opposed  the  doctrines  held  as 
sacred  by  the  pathologist.  No  recognition  has  been 
accorded  to  the  truth  that  in  almost  every  particular 
the  value  of  evidence  obtained  from  the  living  out- 
weighs that  which  is  disclosed  upon  the  post-mortem 
table. 

It  is  not  alone  in  respect  of  the  pathological  changes 
discovered  in  the  conduct  of  an  abdominal  operation 
that  a  new  knowledge  is  growing  up,  but  also  in  refer- 
ence to  the  clinical  manifestations  that  are  attached 
to  these  structural  changes.  The  literature  of  medi- 
cine has  been  too  much  concerned  with  terminal  events. 
It  is  necessary  for  us  now  to  devote  our  closest  inquiry 
to  the  very  earliest  disturbances  of  health  so  that 
medical  treatment  of  a  condition  whose  authentic 
nature  is  known  may  be  more  purposeful,  and  surgical 
treatment,  when  necessary,  adopted  at  an  earher, 
and  in  a  safer,  stage.  One  result  of  the  great  increase 
in  the  number  of  abdominal  operations  in  recent  years 
is  that  the  organic  diseases  affecting  the  several  vis- 
cera  are  being  recognised  in  earlier  stages,  and  that 
the  sjonptoms  aroused  in  these  stages  are  being  given 
a  proper  interpretation.  Another  result  is  the  lessen- 
ing of  the  number  of  so-called  "functional  diseases" 
by  a  recognition  of  the  fact  that  they  are  chiefly 

6 


PREFACE. 


dependent  upon  demonstrable  changes  in  structure. 
If  the  works  of  medicine  of  a  quarter  of  a  century  ago 
are  examined,  it  will  be  realised  that  a  very  great 
majority  of  the  cases  of  "dyspepsia"  were  then  at- 
tributed to  functional  derangements.  We  now  know 
that  among  the  conditions  so  described  were  many 
organic  diseases,  such  as  duodenal  ulcer,  some  of  the 
forms  of  cholelithiasis,  and  last,  but  certainly  greatest, 
chronic  appendicitis.  I  believe  that  time  will  shew 
that  possibly  all,  certainl}^  nearly  all,  of  the  cases  of 
protracted  and  recurring  ''dyspepsia"  are  due  not  to 
vices  of  secretion,  though  indeed  these  may  be  present, 
but  to  organic  changes  in  one  or  other  of  the  viscera. 
What  a  world  of  observations  have  been  conducted 
upon  the  changes  in  the  quantity  and  quality  of  the 
gastric  secretions !  Yet  all  the  while  the  stomach  was 
weeping  only  because  of,  and  in  sympathy  with,  the 
damage  unceasingly  inflicted  upon  other  parts.  It 
is  all  as  though  one  should  attempt  to  discover  the 
place  and  the  nature  of  a  foreign  body  in  the  eye  by  an 
examination  of  the  tears  that  flow  so  freely. 

B.    G.    A.    MOYNIHAN 
33  Park  Square,  Leeds 

St.  Patrick's  Day,  1910 


Contents. 


PAGE 


An  Address  on  The  Pathology  of  the  Living  .     11 

An  Address  on  Inaugural  Symptoms 41 

An  Address  on  Gastro-enterostomy  and  After     71 

The     Early    Dlignosis    and     Treatment    of 

Cancer  of  the  Stomach 95 

Remarks  upon  the  Surgery  of  the  Common 
Bile-duct 125 

The  Operative  Treatment  of  Obstructive 
Jaundice  and  the  Proper  Selection  of 
Cases 177 

On  the  Violation  of  Courvoisier's  Law 201 

The  Mimicry  of  Malignant  Disease  in  the 

Large  Intestine 215 

The  Surgical  Treatment  of  Cancer  of  the 

Sigmoid  Flexure  and  Rectum,  with  Es- 

PECLiL  Reference  to  the  Principles  to 

BE  Observed 233 

Index  of  Authors 245 

Index 249 


AN  ADDRESS 

ON 

The  Pathology  of  the  Living.* 

Delivered    before    the    Ashton-under-Lyne    Di- 
vision OF  THE  British  Medical  Association  at 
THE  Opening  of  the  Winter  Session 
ON  October   18,  1907. 

Mr.  President  and  Gentlemen:  When  I  had  the 
honour  of  receiving  your  most  cordial  invitation  to 
open  the  winter  session  of  this  Division  of  the  British 
Medical  Association,  the  thought  came  to  me  that  I 
might  perhaps  be  able  to  interest  you  by  an  endeavour 
to  show  in  what  manner  our  knowledge  of  the  pathol- 
ogy and  treatment  of  abdominal  diseases  had  been 
modified  and  enlarged  by  the  work  of  the  surgeon. 
Those  among  us  who  can  carry  the  mind  back  twenty 
years  or  thereabouts  will  remember  that  practically 
all  the  knowledge  we  then  possessed  of  the  diseases 
having  their  origin  within  the  abdomen  was  based 
upon  clinical  observations  of  the  symptoms  and  signs 

*  Reprinted  from  the  British  Medical  Journal,  November  16, 
1907. 

11 


THE  PATHOLOGY  OF  THE  LIVING. 

which  the  patient  displayed  during  life,  and  the  patho- 
logical evidence  revealed  upon  the  post-mortem  table. 
At  the  present  time,  however,  as  a  result  of  the  enor- 
mous increase  in  the  number  of  abdominal  operations, 
a  third  and  most  fertile  source  of  information  has  been 
disclosed  to  us.  During  the  conduct  of  such  an  opera- 
tion not  only  are  the  parts  immediately  concerned  in 
the  operation  laid  bare,  but  other  organs  also  are 
exposed  to  our  scrutiny  and  investigation,  with  the 
gradual  result  that  we  have  been  enabled  to  construct 
a  pathology  of  the  living  as  contrasted  with  the  path- 
ology of  the  dead.  It  is  of  the  value  of  this  pathology 
of  the  living  and  of  its  influence  upon  our  powers  of 
diagnosis  and  of  treatment  that  I  wish  more  especially 
to  speak  to-night. 

I  can  well  remember  the  time  when  the  risks 
of  an  abdominal  operation  were  very  considerable. 
When  I  was  first  a  resident  in  the  Leeds  Infirmary 
there  was  a  long  period  in  which  approximately  two- 
thirds  of  all  the  patients  died  after  abdominal  section 
had  been  performed  upon  them.  The  record  of  a 
year's  work  was  not  then  a  chapter  of  great  surgical 
achievements;  it  was  a  martyrology.  This  was,  in 
part,  due  to  the  large  proportion  which  the  desperate, 
the  "too  late,"  cases  of  obstruction  and  similar  troubles 
bore  to  the  total  number  of  operations;   in  part,  also, 

12 


THE  PATHOLOGY  OF  THE  LIVING. 

no  doubt,  to  the  fact  that  in  surgery,  as  in  all  the  arts, 
the  hand  of  the  beginner  is  heavy.  It  was  in  those 
days  not  an  uncommon  experience  for  the  surgeon 
who  recorded  the  discovery  of  certain  pathological 
states  during  the  operation  to  be  held  up  to  good- 
humoured  derision  by  his  colleagues,  or  the  residents, 
when  the  post-mortem  examination  disclosed  a  state 
of  affairs  supposed  to  be  entirely  at  variance  with 
these.  It  never  seemed  to  occur  to  us  that  the  post- 
mortem evidence  was  perhaps  of  far  less  value  and 
significance  than  that  which  had  been  furnished  during 
the  life  of  the  patient.  Yet  it  is  a  fact  hardly  to 
be  questioned  that  there  is  often  a  greater  change 
in  the  naked-eye  appearance  of  the  parts  within  the 
abdomen  after  death  than  there  is  in  the  expression 
of  the  face.  The  features  of  a  man  in  health  change 
greatly  when  death  comes,  and  these  changes  have 
their  counterpart  elsewhere. 

The  knowledge  gleaned  upon  the  operation  table  has 
shown  that  at  least  no  small  part  of  the  post-mortem 
room  pathology  is  in  value  insignificant  as  compared 
with  the  pathology  of  the  living.  This  is,  indeed, 
only  what  might  reasonably  be  expected.  If  a  patient 
is  suffering  from,  a  certain  disease,  say  of  the  stomach 
or  gall-bladder,  it  is  of  greater  import  and  of  greater 
service  to  us  to  see  the  exact  pathological  conditions 

13 


THE  PATHOLOGY  OF  THE  LIVING. 

present  at  the  moment  of  his  illness  than  it  could  be 
to  see  the  same  parts  months  or  years  afterwards, 
when  unalterable  changes,  extensive  advances,  and 
perhaps  a  terminal  infection,  have  been  added  to 
that  early  simple  condition  which  first  disturbed 
the  patient's  health.  It  is  more  important  for  us 
to  know  the  pathological  conditions  which  cause  a 
patient's  present  sufferings — a  pathological  change 
which  is,  perhaps,  remediable — than  it  is  to  know 
the  fullest  particulars  of  that  unhindered  morbid 
change  which  has  at  last  caused  death.  Our  chief 
purpose  is  to  heal  the  living. 

A  point  in  reference  to  the  value  of  post-mortem 
pathology  is,  it  seems  to  me,  too  constantly  overlooked. 
The  evidence  furnished  in  a  series  of  years  in  the  post- 
mortem room  of  a  general  hospital  upon  any  subject 
is  of  enormous  value;  that  no  one  disputes.  But  the 
value  is  necessarily  a  limited  one.  To  take  an  example : 
In  a  recent  discussion^  Dr.  Hale  White  briefly  reviewed 
the  cases  in  which  gall-stones  had  been  found  on  post- 
mortem examination  during  twenty-five  years  at  Guy's 
Hospital.  Within  this  period  11,031  autopsies  had 
been  performed,  and  gall-stones  were  found  in  333 
cases.  There  are  probably  few  hospitals  where  so 
many  post-mortem  examinations  are  made  as  at  Guy's, 
and  it  is  doubtful  if  there  is  one  where  they  are  made 

14 


THE  PATHOLOGY  OF  THE  LIVING. 

with  greater  care  or  accuracy.  Yet  the  first  thought 
that  occurs  to  one  is  that  the  accumulated  experience 
of  all  these  years  at  this  great  hospital  is  very  meagre. 
The  total  number  of  cases  in  which  gall-stones  or  their 
complications  were  found  is  small :  a  great  deal  smaller, 
for  instance,  than  the  number  of  cases  that  have  been 
operated  upon  by  a  few  individual  surgeons.  In  mere 
quantity,  that  is  to  say,  the  entire  post-mortem  ex- 
perience of  this  great  hospital  in  twenty-five  years  is 
less  than  the  experience  of  a  single  surgeon  during, 
say,  five  or  ten  years.  In  actual  value  the  former 
cannot  be  compared  with  the  latter.  For  however 
carefully  the  anamnesis  of  the  dead  patient  may  have 
been  taken,  his  personal  contribution  to  our  knowledge 
is  a  final  and  completed  thing,  amenable  to  no  revision. 
The  surgeon,  on  the  other  hand,  happily,  is  able  to 
co-ordinate  the  details  of  the  patient's  history,  ampli- 
fied and  more  closely  scrutinised,  if  need  be,  after  the 
operation,  with  those  morbid  changes  of  which  the 
operation  has  made  him  fully  cognizant.  If  a  single 
observer  had  been  present  at  every  autopsy  at  this 
hospital  during  all  these  years  (an  impossible  assump- 
tion), his  experience  would  have  a  less  solid  foundation 
in  essential  facts  and  observations  than  that  of  many 
surgeons  who  are  now  daily  engaged  in  the  treatment 
of  patients  suffering  from  this  disease.     It  seems  to 

15 


THE  PATHOLOGY  OF  THE  LIVING. 

me  indisputable  that  the  evidence  which  can  be  ad- 
duced from  the  post-mortem  records  of  any  hospital, 
however  long  the  period  chosen,  in  respect  of  gall-stone 
disease,  of  diseases  of  the  stomach,  or  of  the  pancreas, 
or  intestines  including  the  appendix,  is  inconsiderable 
in  quantity  and  insignificant  in  value  when  compared 
with  that  which  is  now  available  upon  the  operation 
table.  For  it  is,  I  think,  reasonable  to  assert  that 
patients  do  not  commonly  die  in  hospital  as  a  result  of 
the  diseases  from  which  they  suffer  protractedly  during 
life.  The  occurrence  of  an  autopsy  in  hospital  upon 
a  patient  who  has  died  of  calculous  obstruction  of  the 
common  duct  may  be  a  rare  event — one  case  in  forty 
years  at  Guy's  Hospital.  In  my  own  work  such  a  case 
is  now  seen  upon  the  operation  table  on  an  average 
once  in  ten  days.  The  death  in  hospital  of  a  patient 
who  has  at  any  time  suffered  from  gall-stone  disease  is 
evidently  rare,  for  in  twenty-five  years  at  Guy's 
Hospital  only  333  cases  were  seen.  In  six  years  I  have 
myself  seen  a  larger  number  than  this  of  patients  who 
were  so  seriously  troubled  by  this  disease  that  operative 
treatment  was  necessary,  and  Drs.  W.  J.  Mayo  and 
C.  H.  Mayo,  of  Rochester,  have  together  operated 
upon  over  1,500  cases.  Again,  I  could  quote  more 
than  one  eminent  physician  who  considers  that  death 
from  haemorrhage  in  cases  of  gastric  or  duodenal  ulcer 

16 


THE  PATHOLOGY  OF  THE  LIVING. 


is  extremely  rare,  because  in  all  his  hospital  experience 
no  such  case  had  been  known.  Yet  a  little  reflection 
will  show  that  it  is  hardly  to  be  expected  that  such 
cases  would  be  admitted  to  hospital.  Neither  hem- 
orrhage nor  perforation  occurs  except  in  rare  instances 
when  the  patient  is  under  treatment  in  hospital. 
Within  the  last  twelve  months  I  have  seen  three  pa- 
tients suffering  from  chronic  ulcer,  in  two  cases  in 
the  duodenum,  in  one  in  the  stomach,  who,  while 
awaiting  operation,  bled  to  death  before  they  could 
be  admitted  into  hospital.  It  is,  therefore,  hardly 
necessary  to  point  out  that  opinions,  at  times  so 
confidently  expressed,  which  are  based  only  on  post- 
mortem experience,  which  take  no  account  of  the 
sufferings  or  of  the  morbid  changes  in  the  living, 
and  which  show  no  acquaintance  with  the  risks  and 
results  of  operative  treatment,  can  make  no  claim 
upon  our  acceptance  nor  any  serious  demand  upon  our 
consideration. 

Diseases  of  the  Stomach  and  Duodenum. 

But  my  chief  purpose  is  not  merely  to  endeavour 

to  adjust  the  relative  values  of  the  evidence  derivable 

from  the  dead  and  from  the  living,  but  to  attempt  to 

show  what  are  the  contributions  which  have  been  made 

by  the  surgeon  to  the  science  of  medicine  by  his  study 
2  17 


THE  PATHOLOGY  OF  THE  LIVING. 

of  the  pathology  of  the  living.  Let  me  take  the  dis- 
eases of  the  stomach  first.  The  work  of  the  surgeon 
has,  I  think,  shown  that  chronic  ulcer  of  the  stomach 
or  of  the  duodenum  is  a  far  more  common  disease  than 
was  formerly  believed,  and  that  a  very  large  number 
of  the  protracted  or  recurring  cases  of  indigestion  are 
due  to  its  presence.  It  is  no  long  time  since  most  of 
the  symptoms  due  to  ulcer  were  attributed  to  vices  of 
secretion,  to  excess  or  deficiency  of  hydrochloric  acid 
in  the  gastric  juice,  and  so  forth.  But  exploration  of 
the  abdomen  has  shown  that  the  part  played  by  these 
factors  in  the  type  of  case  I  have  mentioned  is  so  small 
as  to  be  almost  negligible.  With  regard  to  duodenal 
ulcer,  it  is  hardly  an  exaggeration  to  say  that  nothing 
was  known  of  its  symptomatology,  and  very  little 
could  be  done  for  its  relief  until  the  surgeon  had  real- 
ised its  frequency  and  had  shown  in  what  manner  the 
patient  could  be  cured.  In  the  text-books,  or  special 
medical  works  on  the  subject,  duodenal  ulcer  is  con- 
sidered an  infrequent  disease,  and  one  very  difficult 
of  recognition.  Both  RiegeP  and  Ewald^  give  such 
meagre  descriptions  of  duodenal  ulcer  that  it  is  quite 
certain  that  the  characteristic  clinical  picture  of  this 
malady  is  unknown  to  them,  and  the  opportunity  of 
co-ordinating  the  anamnesis  with  the  living  pathology 
in  a  case  of  duodenal  ulcer  has  probably  not  occurred 

18 


THE  PATHOLOGY  OF  THE  LIVING. 

to  either  of  them.  The  work  of  the  surgeon  has  showTi 
that  duodenal  ulcer  is  a  common  disease;  I  have  my- 
self operated  upon  150  cases.  In  my  last  pubhshed 
paper  I  showed  that  the  proportion  of  gastric  to  duo- 
denal ulcers  in  mj'  OAvn  cases  w^as  exactly  as  2  to  1. 
Yet  since  then  the  proportions  have  altered,  and  re- 
cently I  have  operated  oftener  for  duodenal  than  for 
gastric  ulcer.  ]Many  of  the  ulcers  which  were  supposed 
to  be  pyloric  or  in  the  stomach  close  to  the  pylorus  we 
now  know  to  be  in  the  duodenum.  To  tell  exactly 
whether  an  ulcer  is  gastric  or  duodenal  is  not  always 
quite  easy;  a  careful  examination  of  the  whole  area 
must  be  made,  and  the  venous  ring  w^hich  usualh^ 
marks  the  site  of  the  pjdorus  defined.  By  multiply- 
ing these  careful  examinations  we  have  come  to  realise 
that  duodenal  ulcer,  at  least  in  the  cases  that  come 
to  the  surgeon  for  treatment,  is  almost,  if  not  quite, 
as  frequent  as  gastric  ulcer.  And  little  by  little  the 
clinical  picture  has  become  complete,  and  a  diagnosis 
of  ulcer  can  now  be  made  wdth  reasonable  certainty 
from  the  anamnesis  alone.  This  is  usually  the  story 
the  patient  tells:  After  food  is  taken  the  patient  is 
free  from  pain;  the  period  of  an  hour  or  tw^o  which 
follows  a  meal  is  the  best  time  in  the  day.  At  a  time 
varjdng  from  one  and  a  half  to  four  hours  after  the 
meal  a  sense  of  uneasiness  is  noted  in  the  upper  part 

19 


THE  PATHOLOGY  OF  THE  LIVING. 

of  the  abdomen.*  A  burning,  gnawing  sensation 
develops,  and  there  is  a  bitter  taste  in  the  mouth, 
with,  it  may  be,  eructations  of  food  or  gas,  bitter  and 
acid  in  taste.  The  pain,  which  gradually  increases, 
may  be  relieved,  often  considerably,  by  belching  or  by 
pressure.  As  it  increases  in  severity  it  strikes  through 
to  the  back,  to  the  right  of  the  middle  line,  and  it  may 
radiate  round  to  the  right  side  of  the  chest.  As  all 
patients  discover  for  themselves,  the  taking  of  food 
relieves  the  pain,  so  that  many  carry  a  biscuit  in  their 
pockets,  or  take  milk,  a  dose  of  an  alkaline  medicine, 
or  some  form  of  food,  as  soon  as  the  uneasiness  de- 
velops. In  several  cases  upon  which  I  have  operated 
the  pain  has  been  more  severe  than  this — has  been, 
in  fact,  indistinguishable  from  a  mild  form  of  hepatic 
colic;  the  patient  described  the  pain,  which  comes 
constantly  two  or  three  hours  after  food,  as  a  ''colic" 
or  a  "spasm."  It  is  not  improbable  that  a  spasm  of 
the  pylorus  is  actually  present,  for  such  a  condition 
may  subsequently  be  seen  during  the  course  of  an 
operation.  The  pain,  it  will  be  noticed,  comes  on  at 
a  time  when  the  patient  should  be  beginning  to  feel 

*  If  the  pain  comes  earlier  than  two  hours,  there  will  usually 
be  found  either  a  commencing  stenosis  of  the  duodenum,  or  a 
mass  of  recent  adhesions  to  the  liver;  if  later  than  two  hours, 
the  ulcer  is  often  seen  to  be  tucked  backwards,  being  adherent 
at  the  upper  part  of  the  right  kidney  pouch. 

20 


THE  PATHOLOGY  OF  THE  LIVINCx. 

hungry  for  his  next  meal;  for  this  reason  the  term 
"hunger-pain,"  which  I  suggested  in  a  former  paper, 
seems  quite  appropriate.  The  interval  of  relief  after 
a  meal  varies  chiefly  according  to  the  character  of  the 
food  taken.  The  more  substantial  the  food,  the  greater 
the  interval  of  relief.  The  appetite  is  generally  good; 
in  fact,  often  better  than  the  normal  if  stenosis  has  not 
developed.  It  is  not  unusual  for  a  patient  to  say, 
"I've  a  good  appetite;  I  can  take  anything,  and  I 
never  vomit."  If  he  has  given  a  history  of  pain,  as 
I  have  described  it,  one  may  be  confident  that  he  has 
duodenal  ulcer,  without  stenosis.  Investigation  by 
test  meals  will  show  no  stasis  and  perhaps,  but  by  no 
means  always,  some  hyperacidity. 

After  a  time — a  few  weeks,  a  month  or  two — the 
symptoms  may  gradually  improve,  and  even  disappear, 
to  reassert  themselves  after  a  longer  or  shorter  in- 
terval. The  patient  will  then  speak  of  having  "at- 
tacks" of  a  certain  duration,  coming  capriciously, 
leaving  spontaneously.  In  the  intervals  between  these 
attacks  he  may  be  perfectly  well,  suffer  absolutely  no 
discomfort,  enjoy  food,  and  gain  weight.  The  attacks 
are  more  frequent  and  more  severe  in  cold  weather 
than  in  warm.  A  "chill "  is  often  assigned  as  a  cause  of 
a  certain  attack,  and  attacks  seem  specially  apt  to 
come  in  times  of  stress  and  worry.     The  recognition  of 

21 


THE  PATHOLOGY  OF  THE  LIVING. 

chronic  duodenal  ulcer  is  most  necessary,  for  it  is,  I 
feel  sure,  a  far  more  serious  disease  than  gastric  ulcer, 
and  it  is,  moreover,  one  which,  in  my  judgement,  should 
always  be  treated  by  operation.  I  often  see  and 
operate  upon  cases  of  duodenal  ulcer  which  have  been 
variously  diagnosed  as  "chronic  gastritis,"  '^acid  dys- 
pepsia," *' hyper  chlorhydria,"  etc.  But  a  slender 
acquaintance  with  the  pathology  of  the  living  is  all 
that  is  needed  to  connect  the  clinical  history  outhned 
above  with  a  condition  of  chronic  ulceration  in  the 
duodenum. 

Another,  and  I  think  incomparably  the  most  im- 
portant, result  of  the  surgical  work  upon  the  stomach 
is  concerned  with  the  relationship  between  chronic 
ulcer  of  the  stomach  and  cancer.  It  is  a  very  remark- 
able coincidence  that  several  surgeons  of  large  experi- 
ence have  noticed  that  when  the  anamnesis  of  the  cases 
of  gastric  cancer  is  studied,  a  clear  history  of  chronic 
ulcer  in  the  stomach  is  given  by  more  than  half  the 
patients.  A  medical  friend  of  mine  to  whom  I  men- 
tioned this  fact  wanted  to  know  the  evidence  which  led 
me  to  the  conclusion  that  an  ulcer  had  been  the  cause 
of  these  early  symptoms.  My  reply  is,  that  if  a  pa- 
tient now  consulted  me,  giving  the  same  history  of  his 
present  sufferings  as  the  cancer  patient  gives  me  of  his 
sufferings  of  ten  or  twenty  years  ago,  I  would  advise 

22 


THE  PATHOLOGY  OF  THE  LIVING. 


surgical  treatment  in  the  confident  expectation  of 
being  able  to  demonstrate  a  chronic  ulcer  as  their 
cause.  And  here  let  me  incidentally  say  that  as  a 
cause  of  symptoms  the  ulcer  which  cannot  be  demon- 
strated does  not  exist,  in  my  opinion.  If  an  ulcer 
justifies  operation  it  is  an  ulcer  which  can  be  seen  and 
felt  and  displayed,  to  the  conviction  of  the  onlooker. 
Unless  a  definite  ulcer  can  be  seen  during  an  operation 
there  is,  in  my  judgement,  no  indication  for  the  perform- 
ance of  gastro-enterostomy.  If  this  operation  is  done 
for  the  relief  of  symptoms  dependent  upon  no  demon- 
strable organic  cause,  the  patient  will  have  no  relief, 
and  the  operation  will  be  thereby  discredited. 

In  cases  of  carcinoma  the  removal  of  the  stomach 
has  furnished  a  few  specimens  which  demonstrate  the 
undoubted  connexion  between  ulcer  and  cancer.  The 
evidence  of  the  development  of  cancer  in  chronic  ulcer 
is  from  the  clinical  side  as  clear  as  it  can  be  in  the 
majority  of  cases;  the  pathological  evidence  is,  of 
course,  more  difficult  to  obtain,  because  it  must  almost 
necessarily  be  based  upon  investigations  of  specimens 
removed  during  life.  For  by  the  time  cancer  of  the 
stomach  has  proved  fatal,  and  the  specimen  is  obtained 
on  the  post-mortem  table,  the  ravages  of  the  disease 
are  so  extensive  that  all  evidences  of  its  origin  in  an 
ulcer   may   be   wholly   obliterated.     But   evidence   is 

23 


THE  PATHOLOGY  OF  THE  LIVING. 

fast  accumulating  which  will  finally  and  completely 
dispel  any  doubts  which  are  still  felt  as  to  the  direct 
influence  of  ulcer  in  the  genesis  of  cancer.  The  argu- 
ments in  favour  of  the  surgical  treatment  of  all  chronic 
ulcers  of  the  stomach  and  duodenum  are  already  suf- 
ficiently strong.  No  other  treatment  than  that  which 
the  surgeon  offers  can  do  more  than  relieve  the  patient 
to  some  extent  of  his  sufferings  when  once  a  chronic 
ulcer  is  established  in  the  stomach;  for  if  the  ulcer 
lying  near  the  pylorus  heal,  its  cicatrix,  while  steadily 
undergoing  contraction,  is  causing  a  constant  mechani- 
cal interference  with  the  movement  of  the  stomach. 
Relief  from  the  misery  which  this  entails  is  offered 
only  by  mechanical  means,  and  no  operation  in  surgery 
gives  more  satisfactory  results  than  gastro-enterostomy 
in  such  circumstances.  The  mortality  of  this  opera- 
tion is  very  small;  its  results  are  extremely  good.  But 
the  argument  for  surgical  treatment  becomes  enor- 
mously strengthened  when  we  are  convinced  of  the 
fact  that  a  large  proportion,  probably  a  majority,  of 
the  cases  of  cancer  that  develop  in  the  stomach  are 
due  to  the  grafting  upon  the  base  of  an  old  ulcer  of  a 
malignant  process.  Surgery,  then,  offers  in  cases  of 
chronic  ulcer  not  only  a  relief  from  present  sufferings, 
but  an  immunity  from  the  possible  onset  of  a  disease 
of  a  far  more  terrible  character.     I  hope  I  may  be 

24 


THE  PATHOLOGY  OF  THE  LIVING. 

allowed  to  insert  here,  perhaps  a  little  irrelevantly,  a 
plea  for  the  earlier  submission  to  the  surgeon  of  cases 
of  cancer  of  the  stomach.  It  is  simply  lamentable  to 
look  through  the  records  of  the  cases  of  cancer  that 
have  been  referred  to  me  or  to  other  surgeons  for 
treatment.  In  the  very  great  majority  the  disease 
is  too  far  advanced  for  anything  but  a  palliative  opera- 
tion, and  in  no  inconsiderable  number  is  the  patient 
so  utterly  exhausted  by  his  disease  that  the  mere 
thought  of  operation  is  repellent.  If  only  the  patients 
who  suffer  from  cancer  of  the  stomach  could  be  seen 
at  an  early  stage  by  the  surgeon,  there  is  no  reason 
why  the  results  of  operative  treatment  should  not  be 
at  least  as  good  as  they  are  in  cases  of  mammary  cancer. 
It  is,  I  submit,  only  by  early  exploration  of  possible 
cases  of  carcinoma  of  the  stomach  that  the  knowledge 
will  be  gained,  by  comparison  of  the  symptoms  with 
the  pathological  conditions  then  disclosed,  which  will 
equip  us  with  the  power  of  early  positive  recognition 
of  this  disease.  At  this  moment  the  most  expert 
clinician  in  the  world  cannot  make  an  early  diagnosis 
of  cancer  of  the  stomach.  If,  then,  patients  suffering 
from  this  disease  are  to  have  any  hope  of  cure,  it  is 
undeniable  that  the  diagnosis  must  be  made  by  in- 
spection of  the  parts  during  hfe.  I  think  there  can 
hardly  be  a  more  promising  occasion  for  the  study  of  the 

25 


THE  PATHOLOGY  OF  THE  LIVING. 

pathology  of  the  living  than  that  afforded  in  the  case 
of  carcinoma  of  the  stomach. 

Diseases  of  the  Biliary  Passages. 

The  work  of  the  surgeon  in  the  diseases  of  the  gall- 
bladder and  bile-ducts  has  also  been  most  fruitful  in 
knowledge.  In  the  early  days  of  gall-bladder  surgery 
but  little  was  known  as  to  the  signs  and  symptoms 
which  arose  from  the  presence  of  stones  in  any  part 
of  the  bile-tract.  The  symptoms  which  were  taken 
to  indicate  the  presence  of  stones  were  in  fact  symptoms 
called  forth  by  the  severe  complications  to  which  those 
stones  gave  rise.  Jaundice,  to  mention  but  one  symp- 
tom, was  looked  upon  as  a  necessary  manifestation 
before  an  unequivocal  diagnosis  of  cholelithiasis  was 
justified;  yet  jaundice  is  a  very  infrequent  symptom 
of  gall-stones,  and  is  not  present  in  by  any  means  all 
the  cases  in  which  a  stone  is  lying  even  in  the  common 
bile-duct.  During  the  course  of  operations  upon  the 
stomach,  appendix,  intestines,  or  pelvic  organs  the 
gall-bladder  can  be  examined,  and  at  times  stones  are 
found  therein  of  which  there  was  no  previous  knowl- 
edge. By  close  inquiry  after  the  patient  has  recovered 
certain  symptoms  are  elicited  which  can  then  with 
confidence  be  attributed  to  the  gall-bladder  disease  of 
which  positive  knowledge  is  now  possessed.     By  such 

26 


THE  PATHOLOGY  OF  THE  LIVING. 

methods,  varied  in  kind,  we  have  acquired  the  knowl- 
edge which  is  indispensable  to  an  early  diagnosis  of 
stone.  Accordingly  we  know  that  the  most  frequent 
manifestation  of  cholelithiasis  is  ''indigestion,"  pain 
after  food,  coming  on  usually  an  hour  or  so  after  a  meal, 
great  discomfort  or  cramp  in  the  epigastrium,  a  feeling 
of  insufferable  distension  relieved  by  belching,  great 
flatulence.  The  pain  is  sometimes  colicky  in  character. 
If  these  symptoms  are  severe  and  recurrent,  elicited 
by  certain  articles  of  diet  and  not  by  others,  a  diagnosis 
of  gall-stones  may  be  safely  made.  Such  a  history 
is  always  obtained  in  those  cases  of  advanced  disease 
which  are  so  frequently  found  on  the  operation  table. 
In  a  case  of  choledochotomy  operated  upon  on  the 
day  I  write  this  paper  the  history  given  by  the  patient 
and  by  the  medical  man  is  that  the  first  ''attack" 
occurred  two  and  a  half  years  ago.  In  that  attack  the 
patient  was  jaundiced.  When  I  elicited  the  anamnesis 
I  asked  directly,  "How  many  years  before  this  attack 
had  you  suffered  from  indigestion?"  The  reply  came 
at  once,  "Oh,  I  have  had  that  trouble  for  over  thirty 
years."  The  history  I  drew  from  the  patient  of  "that 
trouble"  was  the  clearest  evidence  of  the  presence  of 
stones  in  the  gall-bladder;  and  at  the  operation  the 
small,  thickened,  shrunken  gall-bladder,  full  of  stones 
and  buried  in  adhesions,  was  clearly  to  be  held  re- 

27 


THE  PATHOLOGY  OF  THE  LIVING. 

sponsible  for  those  faults  for  which  a  perfectly  healthy 
stomach  had  so  long  been  blamed.  Jaundice,  as  I 
have  said,  is  a  very  uncommon  symptom  in  cholelithia- 
sis. In  my  own  cases  jaundice  at  any  period  has  been 
noticed  in  less  than  25  per  cent.  Jaundice,  which 
Courvoisier  called  the  ''cardinal  symptom"  of  calcu- 
lous obstruction  of  the  common  bile-duct,  may  now 
and  again  be  wanting.  A  few  months  ago  I  removed  a 
stone  as  large  as  a  billiard  chalk  from  the  common-duct 
of  a  man  who  was  not  jaundiced  and  who  never  had 
been  jaundiced,  and  I  find  that  of  31  cases  of  choledoch- 
otomy  performed  by  me  during  this  year,  in  7  jaundice 
was  not  present  at  the  time  of  the  operation.  Yet  in 
6  of  these  cases  the  diagnosis  of  common-duct  obstruc- 
tion was  confidently  made,  because  of  the  rapid  suc- 
cession of  attacks  of  pain,  accompanied  by  shivering 
and  sweating  (a  rigor,  in  fact),  in  a  patient  who  was 
rapidly  losing  flesh. 

It  is  a  disgrace  to  our  diagnostic  acumen  to  admit  it, 
but  it  is  nevertheless  the  fact  that  the  impaction  of  a 
stone  in  the  common  duct  is  not  a  rare  event.  When 
we  have  thoroughly  learnt  our  work,  we  shall  be  able 
to  recognise  the  presence  of  gall-stones  before  this 
serious  and  tardy  complication  of  an  otherwise  simple 
disease  has  developed.  In  almost  all  common-duct 
operations  the  adhesions  are  very  numerous,  and  the 

28 


THE  PATHOLOGY  OF  THE  LIVING. 

gall-bladder  shows  evidence  of  severe  and  long-stand- 
ing disease — chronic  cholecystitis,  with  thickening  and 
sclerosis  of  the  walls  of  the  gall-bladder,  to  a  degree 
which  may  make  the  organ  difficult  to  discover,  or 
even  impossible  to  recognise;  fistulse  may  be  present 
between  the  gall-bladder  and  the  intestine,  the  com- 
mon duct  may  be  so  dilated  as  readily  to  admit  two  or 
three  fingers.  When  the  duct  is  opened,  it  may  con- 
tain many  stones,  pus,  or  offensive  bile,  and  the  hepatic 
ducts  may  be  filled  with  stones  or  black  tenacious  mud. 
Stones  which  I  have  removed  have  been  as  large  as  a 
walnut,  and  in  one  case  over  550  stones  were  numbered, 
and  several  thousands  were  left  uncounted.  Yet  we 
are  gravel}^  told  on  high  authority  that  a  patient  with 
a  stone  in  the  duct  should  not  be  submitted  to  opera- 
tion because  he  is  Hkely  to  recover  if  left  alone.  This 
opinion  is  based  upon  the  fact  that  in  forty  years  only 
one  case  of  common-duct  stone  was  found  on  the  post- 
mortem table  at  Guy's  Hospital.  To  deduce  such  an 
opinion  from  such  a  fact  seems  to  me  to  be  a  shining 
example  of  a  certain  inaccuracy  of  thought  which 
maj'  come  from  a  too  exclusive  devotion  to  the  pathol- 
ogy of  the  dead.  The  most  wholesome  corrective  for 
such  an  error  is  the  close  study  of  the  patholog>^  of  the 
living.     And  unless  an  opinion  is  based  in  some  meas- 


^29 


THE  PATHOLOGY  OF  THE  LIVING. 

ure  upon  the  knowledge  so  acquired,  it  must  always  be 
accepted  with  some  abatement. 

We  are  often  told  that  gall-stones  may  exist  for  years 
in  the  gall-bladder  without  causing  symptoms.  I  do 
not  believe  for  one  moment  that  this  statement  is 
accurate;  it  is  only  another  of  those  legacies  of  error 
which  were  first  bequeathed  to  us  in  the  days  when 
none  but  the  dead  could  disclose  the  secrets  of  pathol- 
ogy, and  which  have  since  been  handed  down  rever- 
ently from  one  generation  to  another.  The  truth  is 
rather  that  those  inaugural  symptoms  which  are 
caused  by  the  stones  as  they  lie  in  the  bladder  are  not 
generally  recognised.  Because  jaundice  has  not  been 
observed,  the  complaints  of  the  patients  are  put  down 
to  ''neuralgia  of  the  stomach,"  or  are  complacently 
ascribed  to  some  other  equally  vague  "disease." 
Whenever  gall-stones  are  discovered  accidentally  dur- 
ing the  performance  of  an  abdominal  operation,  such 
as  hysterectomy,  a  history  of  symptoms  attributable  to 
them  can  in  my  experience  always  be  obtained,  though 
it  is  perhaps  rare  for  an  organic  cause  for  them  to  have 
been  previously  recognised.  So  when  a  necropsy  dis- 
closes gall-stones  it  is  assumed,  with  no  reason,  that 
because  jaundice  or  other  positive  symptoms  are  not 
recorded  the  stones  have  done  nothing  to  excite  recog- 
nition.    I  feel  confident  that  it  is  not  accurate  to  say 

30 


THE  PATHOLOGY  OF  THE  LIVING. 

the  gall-stones  frequently  cause  no  symptoms;  it  is, 
on  the  contrary,  quite  certain  that  they  frequently,  if 
not  constantly,  cause  symptoms  which  we  are  not 
educated  to  recognise.  From  the  dead  no  account  can 
be  obtained  of  their  previous  sufferings,  but  from  the 
patients  who  by  accident  disclose  their  stones  to  the 
eye  of  the  surgeon  much  has  been  and  far  more  may 
be  learnt.  From  them  we  may  glean  much  knowledge 
of  the  pathology  of  the  living. 

Diseases  of  the  Pancreas. 

It  is  as  a  result  of  the  work  of  the  surgeon  upon  the 
biliary  apparatus  that  our  knowledge  of  many  of  the 
diseases  of  the  pancreas  has  been  born.  It  was  in  1896 
that  RiedeP  gave  the  first  detailed  description  of  chronic 
pancreatitis.  He  had  noticed  that  in  certain  operations 
performed  for  cholelithiasis  the  head  of  the  pancreas 
was  considerably  enlarged  and  was  very  indurated; 
its  condition  was,  in  fact,  very  similar  to  that  found 
in  cases  of  primary  malignant  disease.  Riedel  de- 
scribed in  full  3  cases;  in  2  the  patients  recovered  after 
operation,  and  the  pancreatic  enlargement  gradually 
disappeared;  in  the  third  case  the  patient  died,  and 
the  microscopic  examination  of  the  gland  showed  that 
the  tumour  was  due  not  to  carcinoma,  but  to  chronic 
interstitial  inflammation.     But  until  Mayo  Robson's 


THE  PATHOLOGY  OF  THE  LIVING. 

paper  in  1900^  this  subject  did  not  attract  general 
attention,  nor  was  the  clinical  importance  of  chronic 
pancreatitis  adequately  recognised.  It  was  therein 
demonstrated  that  many  cases  formerly  regarded  as 
examples  of  primary  carcinoma  of  the  gland  were  in 
fact  cases  of  chronic  inflammatory  induration  due  to 
irritation  and  infection  by  gall-stones  at  some  time 
present  in  the  common  duct.  The  discrimination  of 
carcinoma  from  chronic  pancreatitis  became  at  once  a 
matter  of  the  highest  importance,  for  it  was  clearly 
recognised  that  the  inflammatory  condition  was  amen- 
able to  surgical  treatment,  whereas  cancer  of  the  gland 
was,  and  still  is,  a  hopelessly  incurable  disease.  The 
differential  diagnosis  remained  in  all  cases  difficult, 
and  in  some  impossible,  until  Cammidge  discovered 
that  the  urine  afforded  important  evidence  in  this 
connexion.  The  value  of  Cammidge's  test  in  cases  of 
pancreatic  disease  has  caused  much  discussion,  and  I 
can  only  here  record  the  fact  that  in  many  doubtful 
and  difficult  cases,  both  before  and  after  operation,  it 
has  given  me  great  help. 

The  fact  that  the  common  bile-duct  is  always  in 
close  proximity  to  the  head  of  the  pancreas  and  that 
in  approximately  two-thirds  of  all  cases  it  actually 
runs  within  the  substance  of  the  gland,  and  that  the 
mucous  membranes  of  the  common  duct  and  of  the 

32 


THE  PATITOT.Or,Y  OF  THE  LIVING. 

pancreatic  duct  are  continuous  at  the  diverticulum  of 
Vater,  account  for  the  frequency  of  the  association  of 
pancreatic  disease  wdth  an  infection  of  the  common 
bile-duct  due  to  stone.  The  inflammation  of  the  pan- 
creas will  persist  so  long  as  the  irritation  and  infection 
are  continuously  excited  by  a  gall-stone;  but — and 
herein  lies  a  serious  factor — when  once  the  pancreatitis 
has  progressed  beyond  a  certain  stage,  it  may  persist 
even  after  the  stone  which  first  caused  it  has  passed  or 
has  been  removed.  Gifford  Nash^  and  others  have 
related  cases  in  which  glycosuria  due  to  pancreatic 
disease  has  subsided  as  soon  as  the  infection  of  the  bile- 
passages  was  relieved  by  drainage.  In  a  case  of  my 
own,  however,  a  case  seen  with  Dr.  Stuart,  of  Settle, 
chronic  pancreatitis  due  to  stones  in  the  common  duct 
was  found;  the  stones  were  removed,  and  the  patient 
made  a  good  recovery,  and  remained  well  for  more  than 
a  year.  Glycosuria  then  developed,  and  the  patient 
died  of  diabetic  coma.  The  sclerosis  of  the  gland  which 
followed  upon  the  chronic  inflammation  had  doubtless 
involved  the  islands  of  Langerhans.  Chronic  pancrea- 
titis in  its  early  forms  no  doubt  passes  often  unrecog- 
nised; it  is  relieved  by  the  treatment  of  the  cholangitis 
which  has  caused  it.  In  the  later  stages,  however,  when 
surgical  intervention  has  been  too  long  delayed,  the  con- 
dition is  one  which  may  prove  of  the  utmost  gravity. 


THE  PATHOLOGY  OF  THE  LIVING. 

Diseases  of  the  Large  Intestine. 

There  are  several  conditions  involving  the  small 
intestine  to  which  I  should  have  wished  to  refer,  but 
time  and  space  forbid.  I  will  ask  your  attention  for 
one  moment,  however,  to  a  remarkable  result  of  a 
study  of  the  living  pathology  in  the  large  intestine. 
In  a  paper  read  last  year  before  the  Clinical  Society  of 
London'  I  drew  attention  to  certain  simple  conditions, 
some  hitherto  undescribed,  in  which  the  mimicry  of 
malignant  disease  in  the  large  bowel  was  complete. 
In  operating  for  supposed  carcinoma  of  the  colon,  re- 
section of  the  growth  is,  if  possible,  performed.  The 
examination  of  the  specimen  subsequently  may  reveal 
no  evidence  whatever  of  a  malignant  growth.  A  hy- 
perplastic tuberculous  tumour,  a  dense  inflammatory 
deposit  in  the  serous  covering,  or  the  formation  of 
many  false  diverticula  with  inflammation  in  and  around 
them,  may  be  found.  Such  conditions  are  clinically 
not  usually  to  be  distinguished  from  malignant  growths, 
and,  but  for  their  removal  by  the  surgeon,  might  have 
waited  long  for  recognition.  Yet  they  are  all  innocent 
conditions,  which,  when  removed,  do  not  recur.  Since 
the  case  of  mimicry  of  carcinoma  by  the  development 
of  false  diverticula,  which  is  recorded  in  my  paper,  I 
have  performed  colectomy  on  a  second  case,  and  have 

34 


THE  PATHOLOGY  OF  THE  LIVING. 

seen  a  third  in  which  a  fistula  had  formed  between  the 
bowel  and  the  bladder.  Indeed,  the  formation  of  a 
vesico-intestinal  fistula  seems  to  be  one  of  the  tendencies 
of  a  perforated  false  diverticulum;  a  search  through 
the  literature  has  shown  that  it  is  far  more  common 
than  was  supposed.  In  cases  where  a  hard  growth 
in  the  intestine  is  accompanied  by  the  passage  of  flatus 
and  fseces  by  the  urethra,  a  diagnosis  of  carcinoma 
seems  irresistible,  yet  the  probability  is  that  ''the 
growth"  would  be  simple,  and  that  the  cause  of  the 
fistula  would  be  a  false  diverticulum,  which  had  bur- 
rowed its  way  through  all  the  coats  of  the  bowel,  and 
thence  through  the  wall  of  the  bladder  which  had  be- 
come adherent.  These  mimicries  of  malignant  dis- 
ease are  found,  of  course,  not  seldom  in  the  stomach, 
but  their  existence  in  the  large  intestine  is  not  generally 
recognised. 

Tuberculous  Peritonitis. 
A  further  illustration  of  the  advantages  of  a  study 
of  the  living  pathology  is  afforded  in  respect  of  tuber- 
culous peritonitis.  Of  the  three  varieties  of  this 
disease,  the  ascitic,  the  fibrous,  and  the  suppurative, 
the  former  alone  lends  itself  to  successful  surgical 
treatment.  The  first  case  in  which  surgical  treatment 
was  adopted  was  the  historical  one  operated  upon  by 

35 


THE  PATHOLOGY  OF  THE  LIVING. 

Sir  Spencer  Wells  in  1862.  The  patient  was  a  female, 
aged  twenty-two,  who  was  believed  to  have  an  ovarian 
tumour.  She  had  been  twice  tapped,  on  one  occasion 
18  pints  having  been  drawn  off;  the  fluid  reaccumu- 
lated,  and  operation  was  advised.  The  abdomen  was 
opened  and  myriads  of  tubercles  were  found  studding 
the  peritoneum.  The  fluid  was  emptied  away  and 
the  abdomen  closed.  The  patient  recovered  after  a 
sharp  attack  of  peritonitis. 

After  this  it  rapidly  became  the  custom  to  operate 
upon  many  cases  of  tuberculous  peritonitis  with  effu- 
sion. It  was  thought  to  be  enough  to  open  the  peri- 
toneal cavity,  to  empty  it,  and  to  close  the  abdominal 
wound  without  drainage.  After  such  treatment  the 
patient's  recovery  was  much  hastened,  and  the  success 
of  the  operation  was  often  very  remarkable.  A  variety 
of  explanations  was  offered  as  to  the  reason  for  the 
undoubted  effect  of  so  simple  a  measure.  But  a  closer 
inquiry  into  the  histories  of  patients  treated  in  this 
way  showed  that  the  ultimate  result  was  not  fully 
satisfactory;  in  a  certain  number  of  cases  the  peritoneal 
affection  recurred,  and  a  second  or  even  a  third  or  a 
fourth  operation  had  to  be  done.  As  a  result  chiefly  of 
the  work  of  J.  B.  Murphy  and  W.  J.  Mayo,  we  have 
been  brought  to  realize  that  the  simple  emptying  of 
the  peritoneal  cavity  is  not  enough.     They  have  shown 

36 


THE  PATHOLOGY  OF  THE  LIVING 


that  tuberculous  peritonitis  is  always  secondary  to  a 
local  infection  (which,  however,  may  itself  be  secondary 
to  disease  elsewhere),   and  that  the  operation  must 
include,  if  permanent  success  is  to  be  ensured,  the  re- 
moval of  this  local  source  of  infection.     This  source, 
which  can  usually,  though  not  always,  be  demonstrated, 
may  be  the  appendix,  the  pelvic  organs  in  the  female, 
or  the  intestine,  and  it  is  curious  that  in  my  last  three 
cases  an  example  of  each  of  these  primary  infections 
was  encountered.     Aitev  the  fluid  is  emptied  away  a 
search  for  the  primary  focus  of  disease  is  made,  and 
this  must  be  removed.     The  results  of  such  treatment 
are  much  better  than  ever  before. 

I  think  it  is  evident  that  the  opportunity  for  an 
early  pathological  examination  in  these  cases  of  ascitic 
tuberculous  disease  is  capable  of  revealing  the  origin  of 
the  infection  in  the  appendix  or  the  Fallopian  tubes, 
whereas  a  later  examination  upon  the  post-mortem 
table  could  only  show  the  universal  havoc  wrought  by 
a  disease  that  had  been  allowed  to  go  on  unchecked  to 
a  fatal  termination.  The  pathology  of  the  dead  in 
such  a  case  is  little  or  no  help  to  the  treatment  of  the 
living.  But  by  operating  at  an  early  stage  the  path- 
ological processes  are  observed  at  a  time  when  they  are 
so  limited  in  extent  as  to  be  removable. 

In  this  very  imperfect  recital  of  a  few  of  the  results 

37 


THE  PATHOLOGY  OF  THE  LIVING 


which  have  come  from  the  work  of  the  surgeon  I  hope 
I  have  said  something  to  convince  you  that  the  study  of 
morbid  conditions  within  the  abdomen  during  the  prog- 
ress of  an  operation  has  materially  increased  our 
capacity  to  make  a  more  certain  and  an  earlier  diag- 
nosis, and  has  accordingly  equipped  us  with  more 
efficient  therapeutic  power.  It  is,  I  submit,  by  a  close 
study  of  the  anamnesis  followed  by  a  careful  investiga- 
tion of  the  parts  implicated  in  the  disease  during  the 
life  of  the  patient  that  the  surest  foundations  for  ac- 
curate diagnostic  power  can  be  built.  The  surgeon, 
after  hearing  the  detailed  story  of  an  illness,  has  not 
to  wait  until  death  comes  to  the  patient  before  he 
can  lay  bare  those  pathological  processes  which  have 
given  rise  to  all  the  symptoms.  He  can  see  and  handle 
the  organ  or  organs  affected  at  the  time  they  are  ex- 
citing the  sufferings  of  the  patient;  not  at  the  time, 
months  or  years  later,  when  all  bounds  have  been 
overstepped  by  the  unchecked  extension  of  the  disease, 
in  parts  laid  waste  by  a  late  infection.  At  the  time 
when  symptoms  are  being  caused,  the  pathological 
changes  are  open  to  examination;  that  is  the  advantage 
which  comes  from  a  study  of  the  pathology  of  the 
living.  So  far  as  abdominal  diseases  are  concerned,  he 
is  the  best  diagnostician  who  spends  much  of  his  time 
in  the  operation  theatre.     The  lessons  there  to  be 

38 


THE  PATHOLOGY  OF  THE  LIVING. 

learnt  are  far  greater  in  number  and  far  outweigh  in 
value  those  that  can  be  learnt  in  the  post-mortem  room, 
in  so  far  as  they  bear  any  reference  to  the  treatment 
of  the  living. 

I  would,  therefore,  urge  upon  all  those  engaged  in 
practice  the  desirability  of  following  their  patients 
to  the  operation  table  whenever  opportunity  occurs. 
The  lessons  there  to  be  learnt  will  in  practice  be  of  a 
value  beyond  all  reckoning,  and  interest  in  the  daily 
work  will  be  thereby  quickened  to  an  unaccustomed 
degree. 

REFERENCES. 

1.  Clinical  Journal,  1907,  xxx,  273. 

2.  Diseases  of  Stomach,  Saunders's  translation,  p.  614. 

3.  Diseases  of  the  Digestive  System,  1907,  p.  198. 

4.  Berl.  khn.  Woch.,  1896,  xxxlii,  1  and  25. 

5.  Lancet,  1900,  ii,  235. 

6.  Ibid.,  1902,  ii,  1192. 

7.  Edinburgh  Medical  Journal,  1907,  i,  228. 


39 


AN  ADDRESS 

ON 


Inaugural  Symptoms.'^ 

Delivered  before  the  Derby  Medical  Society. 

Gentlemen:  In  an  address  which  I  had  the  honour 
to  deUver  before  the  Ashton-under-Lyne  Division  of 
the  British  Medical  Association  a  year  ago,  I  ventured 
to  call  attention  to  what  I  termed  the  "Pathology  of 
the  Living/'  and  I  endeavoured  to  show  in  what  manner 
our  conception  of  various  diseases,  having  their  origin 
within  the  abdomen,  had  become  modified  by  a  study 
of  the  morbid  conditions  disclosed  in  the  course  of  an 
operation.  I  pointed  out  that  much  of  our  knowledge 
of  the  pathological  processes  involving  the  abdominal 
organs  was  based,  chiefly,  if  not  solely,  upon  investiga- 
tions made  in  the  post-mortem  room,  and  I  ventured 
to  assert  that  the  evidence  therein  obtained  was  given 
a  value  greater  than  its  worth,  when  it  came  to  be 
reckoned  as  a  factor  influencing  or  deciding  our  views 
upon  the  question  of  therapeutic  measures.     At  the 

*  Reprinted  from  the  British  Medical  Journal,  November  28,  1908. 

41 


INAUGURAL  SYMPTOMS. 


time  when  the  dead  alone  were  available  for  purposes  of 
accurate  pathological  diagnosis  it  was  the  symptoms 
which  were  manifested  during  the  last  few  weeks  or 
months  of  the  patient's  Hfe  which  chiefly  attracted 
attention.     These  symptoms  were  looked  upon  as  the 
natural  and  necessary  subjective  expressions  of  those 
morbid  conditions  the  final  stages  of  which  were  pres- 
ently displayed  at  the  autopsy.     And  so  when  text- 
books came  to  be  written,  it  was  the  late  symptoms 
and  signs  which,  having  attracted  special  and  recent 
attention,    became    conspicuously    recorded.     It    was 
the  late  manifestations  which  were  thought  to  be  the 
characteristic  manifestations  of  any  form  of  disease, 
and  it  was  upon  them  that  attention  chiefly  centered. 
But  late  symptoms  are,  I  submit,  no  more  characteristic 
of  any  disorder  than  early  ones,  and  their  importance 
as  signals  for  therapeutic  aid  is  relatively  insignificant, 
for  they  come  at  a  time  when  heroic  measures  have  not 
seldom  to  be  adopted  if  the  life  of  the  patient  is  to  be 
saved  or  prolonged.     Late  symptoms  are  too  often  the 
heralds  of  death;  inaugural  symptoms  may  be  the  cry 
for  timely  surgical  assistance. 

In  this  paper  I  wish  to  draw  attention  to  the  urgent 
need  which  exists  for  a  study  of  the  very  early  symp- 
toms of  all  diseases,  but  more  especially  of  those  affect- 
ing many  of  the  abdominal  organs.     The  surgeon,  when 

42 


INAUGURAL  SYMPTOMS. 


he  is  about  to  operate  upon  a  patient  suffering  from 
any  abdominal  disease,  has  the  opportunity  to  observe 
not  only  those  parts  for  which  his  operative  interference 
is  immediately  necessary,  but  also  all  other  viscera 
which  can  be  laid  bare  through  the  same  incision.  If  a 
morbid  process  in  its  earliest  stage  be  then  discovered, 
perhaps  in  parts  other  than  those  primarily  concerned 
in  the  operation,  the  patient's  story  of  his  sufferings 
may  be  retold,  and  cross-examination  conducted  there- 
upon, as  soon  as  recovery  from  the  operation  is  com- 
plete. It  rests,  therefore,  in  no  small  degree,  with  the 
surgeon  to  elicit  the  inaugural  symptoms  associated 
w4th  the  pathological  changes  which  he  finds  T\dthin 
the  abdomen,  and  by  making  sure  of  their  significance 
and  of  the  due  order  of  their  appearance,  to  furnish 
the  knowledge  that  will  ensure  clinical  recognition  of 
visceral  diseases  in  their  early  stages,  in  the  stages 
when  they  are  surely  amenable  to  curative  treatment. 
There  is  immediate  need  for  this  earnest  investiga- 
tion of  inaugiu-al  symptoms.  It  is  a  frequent  and  de- 
pressing experience  for  the  surgeon  to  have  referred 
to  him  cases,  of  malignant  disease  more  especially, 
though  by  no  means  exclusively,  when  the  time  for 
safe  operative  treatment,  with  the  almost  certain  pros- 
pect of  complete  relief,  has  passed  long  ago.  Only  a 
few  days  ago,  by  the  kindness  of  one  of  my  colleagues, 

43 


INAUGURAL  SYMPTOMS. 


I  became  possessed  of  a  specimen  of  chronic  duodenal 
ulcer  which  had  caused  a  patient's  death.  The  man 
had  been  admitted  to  hospital  suffering  from  profuse 
hsematemesis  and  melsena;  he  was  desperately  ill, 
moribund  indeed,  and  he  died  before  the  bleeding  could 
be  checked.  An  ulcer,  the  size  of  a  shilling  and  about 
3^8  inch  deep,  eroded  a  large  vessel  the  orifice  of  which 
was  displayed  in  the  base  of  the  ulcer.  That  ulcer 
had  existed  for  months,  perhaps  for  years;  it  had  long 
called  aloud  for  recognition,  yet  its  cry  had  never 
been  heard  or  heeded,  despite  the  fact  that  the  symp- 
toms of  this  disease  are  as  definite  and  unmistakable 
as  are  those  of  a  broken  limb. 

That  cancer  of  the  stomach  is  a  common  malady  we 
know  well  enough;  it  claims  an  appalling  number  of 
victims  every  year.  It  is  a  disease  which  is  purely 
local  in  its  early  stage,  a  disease  which  accordingly 
lends  itself  readily  enough  to  radical  treatment.  Yet 
it  is  probably  safe  to  say  that  there  are  not  in  all  Eng- 
land ten  patients  who  have  been  cured  of  this  dire 
complaint.  The  tale  of  the  victims  of  appendicitis  is 
told  almost  daily  in  the  newspapers.  If  the  early 
symptoms  of  this  disease  were  commonly  understood 
and  appropriate  treatment  adopted  from  the  first  (not 
necessarily  operative  treatment),  the  terrible  mortality 
would  be  very  considerably  reduced.     I  think  it  is 

44 


INAUGURAL  SYMPTOMS. 


almost  certain  that  the  acute  fulminating    cases  (so 
called)  of  this  disease  give  always  a  definite  warning  of 
their  approach ;  it  is  our  ignorance  of  this  warning  that 
proves  so  disastrous.     How  does  it  come  about,  then, 
that  we  are  so  pitifully  helpless  in  these  and  in  many 
other  like  diseases?     It  is,  I  venture  to  say  confidently, 
because  we  rely  for  our  diagnosis  not  upon  inaugural 
symptoms,   but  upon  those  of  late  appearance;    we 
confuse  far  too  frequently  the  symptoms  of  a  tardy 
complication  with  those  of  the  original  morbid  process 
itself.     We  hesitate  to  diagnose  cancer  of  the  stomach 
before  a  lump  can  be  felt,  and  we  have  not  the  courage, 
in  a  case  of  reasonable  doubt,  to  open  the  abdomen  to 
look.     We  question  the  evidence  of  duodenal  ulcer 
until  haemorrhage  occurs,  though  haemorrhage  is  a  late, 
dangerous,  and  preventable  manifestation.     We  dare 
not  hint  the  presence  of  gall-stones  till  jaundice  comes, 
though  symptoms  of  the  plainest  meaning  have  been 
present  for  years  and  in  spite  of  the  fact  that  jaundice 
is  an  infrequent  symptom  of  gall-stone  disease.     In- 
deed much  of  the  text-book  symptomatology  urgently 
demands  revision.     It  is  based  upon  diagnoses  made 
in  the  advanced  or  terminal  stages  and  verified  upon 
the  dead.     Our  knowledge  now  of  the  '^  pathology  of 
the  living"  must  urge  us  to  scrutinise  the  early  history 
more  closely  and  to  endeavour  to  correlate  the  inau- 

45 


INAUGURAL  SYMPTOMS. 


gural  disturbances  of  health  with  the  morbid  conditions 
responsible  therefor,  which  are  laid  bare  by  opera- 
tion. 

I  think  there  is  a  fault  of  which  we  are  all  in  greater 
or  less  measure  guilty — we  are  very  apt  to  ignore  or 
belittle  the  history  of  the  case  from  the  patient's  point 
of  view,  the  anamnesis,  that  is.  The  word  '' anamne- 
sis" is  one  the  significance  and  the  usefulness  of  which 
seem  to  be  insufficiently  appreciated.  It  means  the 
calHng  again  to  mind  incidents  in  the  past,  the  recollec- 
tion of  occurrences  almost  or  entirely  forgotten  until 
thought  was  concentrated  thereon.  Its  meaning  in 
medicine  accordingly  should  be  the  reproduction  in  the 
patient's  mind  of  the  details  of  the  earhest  clinical 
history.  The  ''previous  history"  as  it  is  generally 
told  in  published  case  reports  is  a  jumble  of  the  state- 
ments of  the  patient  and  of  the  prejudices,  opinions, 
and  reflections  of  the  recorder.  It  is  time  that  the 
word  ''anamnesis"  came  into  general  adoption,  and 
that  it  should  be  held  strictly  to  indicate  the  recollec- 
tion by  the  patient  of  the  details  of  his  illness— that, 
neither  more  nor  less.  The  anamnesis  cannot  be  too 
detailed,  for  it  affords  the  only  authentic  information 
which  can  be  obtained,  and  when  it  is  reviewed  in  the 
light  of  the  fuller  knowledge  which  has  come  to  the 
surgeon   after  the   exposure   and   careful,   purposeful 

46 


INAUGURAL  SYMPTOMS. 


scrutiny  of  the  parts  involved  we  should  little  by  little 
become  confident  in  making  our  diagnoses  at  a  much 
earlier  period  than  now  seems  customary  or  possible. 
A  plan  which  I  frequently  follow  is  to  ask  the  patient 
to  write  for  me  in  the  most  detailed  manner  the  story 
of  his  own  sufferings  from  the  time  of  their  very  earliest 
onset,  exaggerating  nothing,  omitting  nothing  because 
of  its  irrelevance  or  apparent  triviality.  Many  little 
points  may  be  brought  out  in  this  way,  points  which 
are  apt  to  escape  one's  notice  when  the  bedside  exam- 
inations are  being  made. 

It  is  in  dealing  mth  the  acute  catastrophes  occurring 
wathin  the  abdomen  that  we  shall  probably  derive  the 
most  instant  and  striking  advantage  from  an  attentive 
study  of  inaugural  symptoms.  It  is  in  these  cases  that 
minutes  gained  mean  lives  saved;  for  the  earlier  the 
gravity  of  the  case  is  realised  and  surgical  treatment 
adopted,  the  safer  will  the  issue  be.  Other  things  being 
equal,  the  mortality  rises  in  direct  proportion  to  the 
time  which  has  passed  since  the  disaster  occurred. 
Many  of  the  symptoms  and  signs  formerly  described 
as  attendant  upon  the  perforation  of  a  hollow  viscus  are 
not  manifestations  of  that  particular  incident  at  all, 
but  are  evidences  of  a  later  and  preventable  complica- 
tion— acute  diffuse  peritonitis.  To  take  a  specific 
example,  the  perforation  of  a  gastric  or  duodenal  ulcer. 

47 


INAUGURAL  SYMPTOMS. 


But  let  me  first  say  that  a  catastrophe  of  this  kind  is 
almost  always  capable  of  being  forestalled.  Though 
the  onset  of  perforation  in  an  ulcer  is  acute,  the  ulcer 
itself  is  of  the  chronic  type.  It  is  an  ulcer  that  has 
existed  for  months  or  years,  and  it  has  given,  in  almost 
every  instance,  not  only  sustained  evidence  of  its 
existence,  but  a  recent  warning  that  the  pathological 
processes  engaged  in  it  were  becoming  more  acute. 
The  warning,  however,  is  commonly  ignored,  because 
the  significance  and  importance  of  it  are  not  under- 
stood, and  accordingly  a  disaster  is  precipitated. 
There  are  few  catastrophes  occurring  within  the  ab- 
domen that  are  veritably  ''acute."  When  we  speak 
of  such  things  we  refer,  as  a  rule,  to  the  abrupt  in- 
cursion of  acute  symptoms  into  the  even  and  placid 
course  of  a  disorder  whose  more  tranquil  manifesta- 
tions have  been  present  for  months,  or  it  may  even  be 
for  years. 

If  the  account  of  the  perforation  of  an  ulcer  given  in 
most  of  the  text-books  be  examined,  it  will  be  found 
that  collapse,  rapidity  and  poor  quality  of  the  pulse, 
and  distension  of  the  abdomen  are  conspicuously 
mentioned  as  symptoms.  Yet  when  a  case  is  seen  in 
the  early  hours,  not  one  of  these  is  necessarily  present. 
Collapse  is  certainly  not  present,  if  it  is  to  be  measured 
by  the  customary  signs,  for  there  is  usually  a  pulse 

48 


INAUGURAL  SYMPTOMS. 


that  is  not  above  80,  and  of  a  quality  that  is  not  very 
perceptibly  altered  from  the  normal.  But  if  there  is 
intense  pain,  with  the  most  unyielding  stiffness  of  the 
abdominal  muscles,  then  a  perforation  has  probably 
occurred.  When  it  is  remembered  that  the  diaphragm 
is  also  an  abdominal  muscle,  and  that  it  is  held  with  a 
rigidity  that  never  slackens,  the  shallow  thoracic  res- 
piration is  explained  at  once.  The  patient  cannot 
make  any  pretence  to  breathe  deeply,  and  the  replies 
to  one's  questions  are  jerked  out  with  an  effort,  the 
end  of  which  is  cut  short  by  a  spasm  of  pain.  This 
unalterable  resistance  of  the  abdominal  wall  is  doubt- 
less a  reflex  having  for  its  purpose  the  protection  of  the 
acutely  affected  area  by  a  muscular  splint.  The  alert, 
anxious,  apprehensive  look  the  patient  always  wears 
is  the  most  eloquent  evidence  of  his  intense  sufferings. 
These  things,  then — the  sudden  onset  of  an  acute  in- 
tolerable pain  that  does  not  abate,  rigidity  of  all  the 
abdominal  muscles,  light  and  shallow  breathing,  -^dth 
an  inspiratory  phase  that  often  ends  abruptly  in  a 
"catch,"  together  with  the  intensely  anxious  expression 
which  the  face  always  wears — are  ample  warrant  for 
a  diagnosis  of  a  perforation.  A  previous  history  of 
indigestion  is  rarely,  if  ever,  lacking.  A  rapid  pulse- 
rate,  vomiting,  abdominal  distension,  are  not  to  be 
looked  for  among  the  inaugural  symptoms.  They  are 
4  49 


INAUGURAL  SYMPTOMS. 


the  proof  that  precious  time  has  already  been  wasted 
and  a  valuable  opportunity  thrown  away. 

Of  the  symptoms  of  duodenal  ulcer — a  common 
disease,  more  frequent,  indeed,  in  my  recent  and  present 
experience  than  gastric  ulcer — I  have  written  fully 
elsewhere.^  It  is  a  very  curious  feature  in  connexion 
with  this  disease  that  perfectly  accurate  accounts  of 
its  symptomatology  are  given  by  authors  who  do  not 
seem  to  have  the  remotest  conception  that  the  con- 
dition they  are  describing  is  not,  as  they  suppose,  one 
of  ''functional"  disorder,  but  one  in  which  a  demon- 
strable organic  lesion  is  present.  The  vague  terms 
''hyperchlorhydria,"  "acid  dyspepsia,"  ''nervous  dys- 
pepsia,'^ are  given  very  generally  as  diagnoses;  they 
are  too  often  words  without  meaning,  clinical  synonyms 
for  the  pathological  condition  duodenal  ulcer.  This  is 
a  disease  which,  left  to  itself  or  attacked  in  the  most 
approved  manner  by  diet  or  by  drugs,  is  a  very  serious 
menace  to  health  and  frequently  imperils  the  life  of 
the  patient.  I  have  already  referred  to  haemorrhage 
in  connexion  with  this  disorder.  Now,  haemorrhage 
is,  almost  without  exception,  a  very  late  symptom  of 
duodenal  ulcer;  it  is  an  evidence  that  a  diagnosis  which 
should  have  been  made  earlier  has  been  missed.  Yet 
what  do  the  text-books  say?  In  NothnageFs  "En- 
cyclopaedia"   (page   245)    we   are   told   that    "severe 

50 


INAUGURAL  SYMPTOMS. 


haemorrhage  occurs  in  about  one-third  of  the  cases," 
and  Cullen,  Fenwick,  and  Perry  and  Shaw  are  quoted, 
who  variously  estimate  the  death-rate  from  haemor- 
rhage as  from  13  to  36  per  cent.  Surely  it  is  almost  as 
reasonable  to  wait  for  haemorrhage  before  venturing 
to  diagnose  a  duodenal  ulcer  as  to  include  a  ruptured 
perineum  among  the  signs  of  pregnancy. 

I  am  disposed  to  think  that  we  shall  be  repaid  seven- 
fold by  a  very  close  attention  to  the  inaugural  symp- 
toms of  gall-stone  disease.  At  the  present  time  no 
slightest  notice  is  paid  to  them  in  the  ordinary  text- 
books on  medicine.  Here  I  deliberately  select  one  of 
them  for  quotation,  because  it  lies  always  near  my 
hand  and  because  it  is  written  by  the  ablest  authority 
I  know — one  of  the  choice  and  master  spirits  of  this 
age,  who  has  always  displayed  a  great  interest  in 
surgical  work  and  an  intimate  knowledge  of  surgical 
literature.  Therein  it  is  written:  'Tn  a  majority  of 
cases  gall-stones  cause  no  symptoms.  The  gall-bladder 
will  tolerate  the  presence  of  large  numbers  for  an  in- 
definite period  of  time " ;  and  again:  ''It  will  be  better, 
perhaps,  to  consider  cholelithiasis  under  the  following 
headings.  The  symptoms  produced  by  the  passage  of 
a  stone  through  the  ducts — biliary  colic;  the  effects 
of  permanent  plugging  of  the  cystic  duct;  of  the  stone 
in  the  common  duct,  and  the  more  remote  effects  due 

51 


INAUGURAL  SYMPTOMS. 


to  ulceration,  perforation,  and  the  establishment  of 
fistulae."  Then  follows  a  detailed  description  of  the 
symptoms  of  the  disease  in  these  various  terminal 
stages.  There  is  no  mention,  it  will  be  seen,  of  any 
early  symptoms,  nor  of  the  symptoms  which  are  due 
to  any  other  than  late  and,  as  I  hold,  preventable, 
complications.  The  very  accurate  descriptions  which 
follow  refer,  all  of  them,  to  the  stages  of  gall-stone 
disease  which  it  should  be  our  business  to  forestall  by 
removal  of  the  offending  cause  in  the  early  days. 

The  only  authority,  so  far  as  I  am  aware,  who  has 
directed  special  attention  to  the  early  symptoms 
caused  by  gall-stones  is  Kraus,^  who  describes  what  he 
terms  a  ''prodromal  stage  of  cholelithiasis."  He  gives 
a  clear  account  of  the  fairly  early  symptoms  by  which 
gall-stones  announce  their  presence;  his  description  is 
accurate,  not  for  the  period  during  which  gall-stones 
are  possibly  forming,  but  for  the  period  when  they  are 
already  present  and  are  bent  on  making  their  where- 
abouts known.  It  is  of  the  greatest  importance  to 
recognise  that  the  inaugural  symptoms  due  to  gall- 
stones are  referred  in  the  anamnesis,  not  to  the  liver 
or  to  the  gall-bladder,  but  to  the  stomach.  The  pa- 
tients complain  of  a  fullness,  weight,  distension,  or 
oppression  in  the  epigastrium  coming  soon  after  meals, 
usually  within  half  or  three-quarters  of  an  hour,  re- 

52 


INAUGURAL  SYMPTOMS. 


lieved  by  belching,  and  dismissed  almost  on  the  instant 
by  vomiting,  elicited  with  remarkable  constancy  by 
certain  articles  of  diet  and  dependent  rather  upon  the 
quality  than  upon  the  quantity  of  the  food.  There  is 
a  sensation  of  great  tightness,  which,  if  unrelieved, 
may  become  acute  pain,  from  which  the  patient  obtains 
ease  by  bending  the  body  forwards,  by  flexing  the  right 
thigh  on  the  abdomen,  or  by  loosening  all  garments 
which  fit  tightly  to  the  waist.  There  is  frequently 
great  complaint  of  '^acidity"  or  heartburn,  and  in  the 
act  of  belching  there  may  be  sour  or  acid  regurgitation. 
While  the  discomfort  lasts  the  patient  may  notice  a 
''catch"  in  his  breath,  and  he  finds,  perhaps,  that  it  is 
impossible  to  breathe  deeply  without  feeling  an  acute 
stabbing  pain  at  the  right  costal  margin.  There  may 
be  a  feeling  of  faintness  and  nausea,  and,  rarely,  vomit- 
ing may  occur  spontaneously.  After  a  more  than 
usually  severe  attack  of  ''indigestion"  the  body  and 
side  may  feel  stiff  for  several  days.  A  frequent  and  a 
very  characteristic  early  symptom  of  cholelithiasis  is 
the  occurrence  during  an  attack  of  indigestion  of  a 
slight  sensation  of  chilliness,  especially  in  the  evenings, 
after  a  meal.  The  patient  may  shiver  for  several 
minutes,  and  may  hasten  from  the  table  to  huddle 
over  a  fire.  The  sensation  of  "goose  flesh"  is  often  ex- 
perienced, and  several  medical  men  upon  whom  I  have 

53 


INAUGURAL  SYMPTOMS. 


operated  have  said  that  in  the  severer  phases  it  was  not 
unhke  a  very  slight  rigor,  the  chilly  stage  being  quickly 
followed  by  one  in  which  the  body  feels  hot,  and  the 
skin  begins  to  act  freely.  My  friend,  Dr.  Leonard 
Molloy,  who  is  very  quick  to  recognise  the  presence  of 
gall-stones,  groups  all  these  symptoms  in  the  phrase, 
"gall-bladder  dyspepsia." 

It  is  no  doubt  owing  to  the  fact  that  these  inaugural 
symptoms  of  cholelithiasis  are  not  generally  recognised 
that  the  pernicious  and  inveterate  heresy,  which  asserts 
that  calculi  may  commonly  exist  in  the  gall-bladder 
without  causing  trouble,  is  still  abroad,  and  is  still 
complacently  accepted  as  an  article  of  faith  by  every 
physician  and  by  many  surgeons.  Naunyn  writes 
(p.  56):  ''Cholelithiasis  is,  as  post-mortem  observa- 
tions show,  an  extraordinarily  common  malady.  On 
an  average  every  tenth  human  being,  and  of  elderly 
women  perhaps  every  fourth,  has  gall-stones.  This 
does  not,  of  course,  express  the  frequency  with  which 
biliary  calculi  give  rise  to  morbid  phenomena,  for  one 
often  enough  finds,  post  mortem,  the  gall-bladder  and 
bile-ducts  completely  packed  with  calculi,  although 
these  have  never  caused  any  inconvenience  or  produced 
any  ill  effects.  In  such  cases  cholelithiasis  may  be  a 
perfectly  harmless  condition,  and  not  merely  a  latent 
one."    It  is  to  be  admitted  at  once  that  gall-stones 

54 


INAUGURAL  SYMPTOMS. 


may  exist  without  arousing  those  symptoms  which 
Naunyn  proceeds  to  describe  in  the  most  admirable 
manner,  the  symptoms  which  have  a  text-book  au- 
thority— the  late  symptoms.  But  I  have  no  hesitation 
in  affirming  that  it  is  excessively  rare  for  symptoms, 
which  are  plain  enough  in  their  meaning  if  only  we  had 
the  intelligence  to  recognise  them,  to  be  absent  when 
stones  lie  within  the  gall-bladder.  Probably  the  only 
circumstance  which  in  such  cases  prevents  their  ap- 
pearance, or  rather  is  responsible  at  last  for  their 
cessation,  is  the  closure  of  the  cystic  duct.  The  gall- 
bladder is  then  no  longer  a  reservoir  for  bile;  it  is  out 
of  the  circuit,  so  to  speak,  and  the  stones  which  lie 
within  it  are  inert  foreign  bodies  of  the  same  kind  as  the 
bullet  which  lies  embedded  and  encapsuled  in  the 
muscles  of  the  thigh.  This  condition  is  one  to  which 
that  very  able  surgeon,  Mr.  Rutherford  Morison, 
applied  the  term  ''natural  cure."  A  sort  of  cholecys- 
tectomy has  been  performed  by  nature's  rough  hand 
in  the  tedious  and  dangerous  attempt  to  give  relief  by 
isolating  a  cause  of  persistent  irritation.  Symptoms 
of  the  kind  described  then  cease  to  appear,  but  the 
fact  of  their  presence  at  an  earlier  period  hardly  fails 
to  be  elicited  when  purposeful  inquiry  is  made.  With 
the  rarest  exceptions,  therefore,  I  believe  it  to  be  true 
that  stones  do  not  develop  in  the  gall-bladder,  and  do 

55 


INAUGURAL  SYMPTOMS. 


not  remain  there  after  their  formation  without  exciting 
symptoms  of  a  kind  which  we  have  neglected  ade- 
quately to  study.  In  my  own  experience,  which  is  not 
inconsiderable,  I  have  never  yet  found  gall-stones  in 
the  gall-bladder,  when  performing  other  abdominal 
operations,  without  being  able  subsequently  to  elicit 
the  most  positive  evidence  of  their  frequent  endeavours 
to  attract  attention  and  to  reveal  their  presence. 

The  most  melancholy  part  of  my  own  daily  work  is 
that  concerned  with  the  treatment  of  cases  of  carcinoma 
of  the  stomach.  It  is  true  that  in  some  instances 
where  I  have  performed  partial  gastrectomy,  and  in 
one  where  the  whole  stomach  was  removed,  the  results 
have  been  very  gratifying.  These  cases  show  what 
may  be  done  in  the  way  of  radical  treatment  for  this 
frequent  and  horrible  disease.  Yet  they  leave  one  full 
of  regret  that  they  bear  so  very  small  a  proportion  to 
the  total  number  of  cases  that  are  referred  to  us  for 
advice  or  for  treatment.  Nothing  to  me  is  more  de- 
pressing than  to  be  compelled  to  confess  in  a  case  of 
cancer  of  the  stomach  that  surgical  treatment  offers 
no  prospect  of  any  the  slightest  relief,  even  for  a  few 
weeks  or  months,  to  the  patient's  pitiful  condition. 
Yet  of  cancer  of  the  stomach  it  is  perfectly  accurate  to 
say  that  it  is  often  a  disease  which  timely  treatment 
could  have  prevented,  and  one  with  which  surgery 

56 


INAUGURAL  SYMPTOMS. 


should  be  able  successfully  to  grapple.     The  truth  of 
the  former  of  these  statements  depends  upon  the  dem- 
onstration of  the  connexion  between  chronic  ulcer  of 
the  stomach  and  carcinoma.     The  anamnesis  of  pa- 
tients suffering  from  cancer  of  the  stomach  seems  to 
indicate  that  in  rather  more  than  60  per  cent,  of  the 
cases  a  chronic  ulcer  has  preceded  the  onset  of  malig- 
nant disease.     The  pathological  evidence  now  available 
shows  that  cancer  develops  in  connexion  with  an  ulcer 
in  something  more  than  50  per  cent.     We  have  waited 
long  for  the  pathological  proof  of  that  which  clinically 
we  had  long  suspected;    such  proof  can  only  be  fur- 
nished by  specimens  examined  in  a  stage  where  the 
transformation  is  not  yet  complete.     The  simple  ulcer 
and  the  malignant  degeneration  must  exist  side  by 
side,  and  the  former  must  be  of  greater  age  than  the 
latter.     Specimens  of  this  kind  are  hardly  to  be  found 
on  the  post-mortem  table,  in  the  bodies  of  those  who 
have  fallen  victims  to  the  unchecked  ravages  of  this 
disease;    they  must  be  obtained  from  the  operation 
theatre.     It  is  in  the  examination  of  specimens  of  par- 
tial gastrectomy  that  the  convincing  pathological  evi- 
dence has  now  been  found.     Dr.  W.  J.  Mayo,  who  in 
this  matter  is  not  exceeded  in  experience  or  authority 
by  any  living  surgeon,  found  that,  in  180  cases  of  re- 
section of  the  stomach,  cancer  was  demonstrated  to 

57 


INAUGURAL  SYMPTOMS. 


have  sprung  up  in  the  base  of  an  ulcer  in  97,  that  is, 
in  54  per  cent.*  The  surgical  treatment  of  chronic 
gastric  ulcer  may,  then,  be  confidently  expected  to 
diminish  the  number  of  cases  of  cancer  of  the  stomach, 
if  the  latter  is  not  seldom  the  tardy  result  of  the  former. 
The  possibility  of  a  radical  cure  of  cancer  of  the  stomach 
once  developed  depends  upon  our  knowledge  of  its 
mode  of  spreading  in  the  stomach  itself,  and  of  the 
distribution  of  the  lymphatic  vessels  and  glands  of  the 
parts  involved.  As  a  result  of  the  researches  of  Cuneo 
and  others,  we  are  well  equipped  with  information  on 
these  points.  Cancer  of  the  stomach,  then,  should  not 
be  the  almost  certainly  fatal  disease  which  it  is  at  this 
moment.  All  that  is  necessary  is  the  recognition  of 
the  cases  in  an  early  stage,  and  this  can  only  be  achieved 
by  earnest  research  into  the  inaugural  symptoms.  Of 
cancer  of  the  stomach  I  described^  two  types  as  they 
affect  the  distal  half  of  this  organ,  the  ''pyloric"  and 
the  ''prepyloric."  In  the  former  the  symptoms  are 
obstructive  from  the  beginning,  and  vomiting  appears 
when  the  disease  is  in  its  earliest  stage.  Stasis  then  is 
present,  and  it  is  not  long  before  some  hypertrophy  of 
the  wall  of  the  stomach  occurs.  These  cases  should 
admit  of  early  recognition  and  of  very  successful 
treatment,  for  there  is  no  other  cure  of  a  mechanical 
obstruction  in  the  stomach  than  that  which  surgery 

58 


INAUGURAT.  SYMPTOMS. 


offers.     In  the  ''prepyloric"  form  the  inaugural  symp- 
toms are  individually  vague,  but  collectively  enable  a 
certain  diagnosis  to  be  made.     A  man  beyond  middle 
life  finds  by  degrees  that  he  takes  less  interest  in  his 
meals;   his  food  loses  its  relish  and  presently  becomes 
distasteful.     Life  in  many  of  its  aspects  seems  to  lose 
its  zest;  neither  work  nor  leisure  is  enjoyed,  and  de- 
pression, increasing  anaemia,  and  loss  of  weight  are  soon 
observed.     It  is  not  for  many  weeks,  or  perhaps  many 
months,  that  vomiting  is  noticed;  it  is  then  due  to  the 
gradual  enlargement  of  a  growth  which,  beginning  on 
the  lesser  curvature  of  the  stomach,  spreads  downwards, 
on  one  or  both  surfaces,  until  it  attains  such  size  that 
the  pyloric  antrum  becomes  narrowed,  and  obstruction 
results.     In  several  of  my  cases  haemorrhage  has  been 
the  first  symptom.     I  had  under  my  care  recently  a 
gentleman  of  sixty-seven,  referred  to  me  by  Dr.  Malim, 
of   Rochdale,    who   suddenly,   without   any   warning, 
when  feeling  in  robust  health,  vomited  a  very  large 
quantity  of  blood  and  fainted.     Soon  afterwards  the 
symptoms  I  have  just  detailed  made  their  appearance, 
and  at  the  operation  a  growth  of  the  prepyloric  form 
was  discovered.     An  exactly  similar  beginning  occurred 
in  a  case  kindly  sent  to  me  by  Dr.  Daly,  of  Hull,  a  few 
months  ago,  and  I  have  notes  of  several  other  instances. 
The  sudden  occurrence  of  profuse  haematemesis  in  a 

59 


INAUGURAL  SYMPTOMS. 


man  previously  in  good  health  is  to  be  looked  upon  as 
especially  significant.  We  should  have  our  suspicions 
keenly  aroused  if,  in  a  patient  at  or  beyond  middle  life, 
whose  anamnesis  tells  of  the  existence  at  some  earlier 
time  of  a  chronic  gastric  ulcer,  there  develop  distaste 
for  food,  loss  of  appetite,  intolerance  and  positive  re- 
fusal of  solid  food,  uneasiness  after  meals,  even  the 
restricted  ones  taken  unwillingly,  loss  of  weight,  per- 
sisting anaemia,  the  gushing  of  acid  or  bitter  clear 
fluids  from  the  stomach  into  the  mouth,  and  vomit- 
ing or  hsematemesis.  Then  exploration  should  be 
urged,  for  in  the  present  state  of  our  knowledge  of 
the  early  symptoms  there  is  no  other  method  by 
which  an  early  carcinoma  of  the  stomach  can  be 
discovered.  No  one  deprecates  more  strongly  than 
I  the  haphazard  exploration  of  the  abdomen  for 
diagnostic  purposes.  I  think  the  most  sedulous  care 
should  be  expended  on  the  examination  of  the  patient, 
and  that  every  detail  of  the  anamnesis  should  be  scru- 
tinised before  the  abdomen  is  opened,  otherwise  we 
may  let  slip  great  opportunities  for  clinical  research. 
We  cannot  correlate  the  clinical  discoveries  on  the 
one  hand,  and  the  disclosures  of  the  operation  on  the 
other,  if  we  are  perfunctory  or  neglectful  in  our  acquisi- 
tion of  the  former.  But  it  would  be  foolish  not  to 
accept  the  position  that  at  this  moment  there  is  no 

60 


INAUGURAL  SYMPTOMS. 


means  of  making  an  assured  diagnosis  of  cancer  of  the 
stomach  in  the  curable  stage  by  any  other  means  than 
the  inspection  of  the  parts  as  to  whose  integrity  there 
is  reasonable  doubt.  It  may  not  be  wholly  inoppor- 
tune to  suggest  that  the  system  which  at  present  ob- 
tains in  many  hospitals  of  admitting  and  of  retaining 
cases  of  cancer  of  the  stomach  under  the  care  of  a 
physician  is  wrong.  There  is  no  medical  treatment  of 
this  condition.  If  the  patient  is  to  have  any  chance  of 
substantial  relief,  or  the  slender  prospect  of  cure,  it 
can  only  be  through  means  which  the  surgeon  alone  is 
competent  to  employ. 

The  treatment  of  cancer  of  the  large  intestine  is  also 
greatly  handicapped  by  reason  of  a  lack  of  adequate 
knowledge  of  inaugural  signs  and  sjnnptoms.  During 
the  last  few  years  I  have  performed  colectomy  in  a 
large  number  of  cases,  and  Tvdth  one  exception  operative 
intervention  became  necessary  because  of  the  onset  of 
acute  or  chronic  obstruction,  or  because  a  tumour  had 
been  discovered  in  the  large  intestine.  The  presence 
of  a  tumour  so  large  as  to  be  felt  through  the  abdominal 
wall  and  the  occurrence  of  an  acute  obstruction  are 
both  evidence  of  ancient  disease;  for  the  intestinal 
growth  is  usually  slow  in  its  rate  of  increase,  though  not 
invariably  so,  and  an  acute  obstruction  comes  ordi- 
narily only  as  a  terminal  manifestation  in  the  course  of 

61 


INAUGURAL  SYMPTOMS. 


chronic  intestinal  disorder.  Now,  it  is  of  the  most 
urgent  importance  that  the  very  earhest  disturbances  of 
health  due  to  cancer  should  be  recognised,  for  cancer 
here,  as  elsewhere,  is  at  first  a  local  disease;  and  be- 
cause local  and  while  local  is  surely  amenable  to  com- 
plete eradication.  In  the  case  of  carcinoma  of  the 
colon  there  are  many  points  which  in  this  special  in- 
stance should  make  for  complete  success  when  the 
neoplasm  is  removed.  The  growth  is  as  a  rule  slow, 
the  lymphatic  supply  of  the  colon  as  a  whole  is  not 
very  free,  the  lymphatic  system  in  all  parts  lends  itself 
to  very  thorough  removal,  and  is  not  invaded  very  early 
in  the  course  of  the  disease.  Furthermore,  by  means 
of  a  procedure  to  which  I  recently  drew  attention,'' 
great  lengths  of  the  large  bowel  can  be  removed  with- 
out risk  of  damage  to  the  vascular  supply,  and  with  the 
certainty  that  end-to-end  anastomosis  can  be  obtained. 
An  early  operation,  if  conducted  upon  the  proper  lines, 
should  therefore  give  very  gratifying  results.  What, 
then,  are  the  earliest  evidences  of  the  invasion  of  the 
colon  by  carcinoma?  The  first,  I  think,  is  the  insidious 
onset  of  intestinal  irregularity.  The  bowel  acts  with  a 
certain  caprice,  there  is  now  slight  constipation,  and 
now  slight  diarrhoea.  These  symptoms  become,  of 
course,  considerably  emphasised  at  a  later  stage,  where 
there  may  be  intestinal  obstruction  of  three  or  four 

62 


INAUGURAL  SYMPTOMS. 


da3's'  duration,  alternating  with  a  copious  and  teasing 
diarrhoea.  But  something  much  less  than  this  occurs 
quite  early  in  the  disease,  and  at  the  same  time  there 
is  commonly  present  a  symptom  which  I  hold  to  be  of 
great  significance.  It  is  the  occurrence  of  a  spasm, 
slight  and  transient,  in  a  part  of  the  large  intestine. 
The  patient  tells  us  that  every  now  and  then  there  is  a 
feeling  of  '^gripping"  (or  he  may  himself  use  the  word 
"spasm ")  in  a  certain  very  limited  area  of  the  abdomen, 
and  he  points  always  to  the  same  spot.  This  is  clearly 
to  be  explained  by  the  existence  of  a  slight  hypertrophy 
of  the  intestinal  muscle  as  a  result  of  the  increased  effort 
necessary  to  pass  the  contents  of  the  gut  through  a 
segment  in  which  stenosis  is  already  beginning  to 
appear.  A  patient  upon  whom  I  recently  operated  for 
a  growth  in  the  sigmoid  flexure  described  this  sensation 
to  me  in  these  words:  "I  feel  as  if  a  hand  within  my 
body  tightened  every  few  minutes,  trying  to  grip  my 
watch."  At  the  same  time  borborygmi  are  heard,  and 
their  onset  is  found  to  synchronise  with  the  sensation 
of  spasmodic  pain.  There  is  no  disease  having  its 
place  within  the  abdomen  that  the  patient  himself  can 
so  accurately  locate  as  carcinoma  of  the  large  bowel. 

The  occurrence  of  mucus  or  of  occult  blood  in  the 
stools  is  probably  to  be  expected  in  the  comparatively 
early  stages  also.     I  have  recently  received  help  in  the 

63 


INAUGURAL  SYMPTOMS. 


diagnosis  of  cases  of  obstruction  in  the  large  intestine 
from  the  examination  by  the  a:-rays  of  patients  to  whom 
bismuth  had  been  administered  by  the  mouth.  The 
presence  of  an  impediment  to  the  easy  passage  onward 
of  the  faecal  current  may  be  graphically  depicted  by  the 
accumulation  of  the  shadow-throwing  bismuth  behind 
the  point  of  constriction  in  the  intestine.  When, 
therefore,  any  or  all  of  these  several  points  are  elicited 
in  a  patient  of  middle  age  or  over,  and  when  loss  of 
weight,  indifference  to  food,  or  positive  repugnance  to 
it,  or  the  deliberate  avoidance  of  the  more  substantial 
meats,  are  together  observed,  there  is  every  probability 
that  serious  organic  disease  is  present  in  the  large  in- 
testine. 

Of  all  the  diseases  affecting  the  abdominal  organs, 
there  is  none  that  may  appear  in  such  varied  form  as 
appendicitis.  A  slight  attack  may  pass  often  unrecog- 
nised, its  nature  being  elucidated  only  when  a  similar 
onset  leads  on  a  later  occasion  to  a  more  severe  attack, 
and  an  operation  for  the  evacuation  of  pus  or  for 
the  removal  of  the  appendix  then  becomes  necessary. 
In  all  instances,  however,  pain  is  the  inaugural  symp- 
tom; if  other  symptoms  appear  first,  the  diagnosis 
must  be  looked  upon  with  suspicion.  Only  recently  I 
have  verified  once  again  this  rule,  upon  which  that  most 
acute  observer,  Dr.  J.  B.  Murphy,  has  so  long  insisted. 

64 


INAUGURAL  SYMPTOMS. 


A  lady,  aged  fifty,  whom  I  saw  with  Mr.  Jalland,  of  York, 
woke  on  a  certain  Friday  morning  at  5  o'clock,  in  a  rigor.  She 
was  shivering  violently,  and  her  temperature  ran  up  to  103°. 
She  had  no  pain  then,  or  at  any  time  during  the  day,  but  remained 
in  bed,  as  she  felt  weak  and  ill.  At  almost  the  same  hour  on 
Saturday  morning  she  had  another  rigor,  and  again  another 
at  7  o'clock  on  Saturday  evening,  and  while  this  rigor  was  in 
progress  she  had  a  sudden  and  very  severe  attack  of  pain  in  the 
abdomen,  and  a  very  sharp  attack  of  diarrhoea  followed.  There 
was  no  vomiting,  but  a  decided  feehng  of  nausea.  During 
Sunday  the  pain  continued,  being  worse  every  hour  or  two, 
as  "spasms"  of  it  came,  and  the  abdomen  gradually  distended. 
I  saw  her  earlj'  on  Monday.  The  abdomen  was  full,  especially 
in  its  lower  half,  and  the  muscles  were  tightly  held.  The  whole 
of  the  lower  part  of  the  abdomen  was  tender;  there  was  tender- 
ness on  vaginal  examination,  and  the  uterus,  as  was  previously 
known,  was  enlarged  to  the  size  of  an  orange  by  a  fibroid.  The 
temperature  was  100°,  the  pulse  100.  The  bowels  had  acted 
well  after  an  enema.  Mr.  Jalland  was  convinced  that  the 
condition  was  steadily  getting  worse,  and  the  evidences  of  a 
spreading  peritonitis  were  unmistakable.  The  most  likely 
diagnosis  seemed  to  me  to  be  perforative  peritonitis;  but  pain 
was  not  the  inaugural  symptom.  In  discussing  the  case  before 
operation  I  made  the  remark  to  Mr,  Jalland  that  the  signs  were 
those  of  an  acute  perforative  appendicitis,  but  that  the  initial 
symptom,  pain,  invariable  in  appendicitis  in  my  experience, 
was  absent.  I  opened  the  abdomen  and  verified  Mr.  JaUand's 
original  diagnosis — a  remarkably  astute  one,  I  think.  There 
was  a  perforation  at  the  fundus  of  the  uterus  from  which  offensive 
pus  was  oozing.  An  abscess  in  the  wall  of  the  uterus  had 
ruptured  into  the  general  peritoneal  cavity,  wherein  we  found 
a  very  large  quantity  of  the  most  offensive  pus.  I  performed 
hysterectomy  and  drained  the  abdomen.  The  patient  has 
happily  made  an  excellent  recovery. 

The   significance   of   the   inaugural   symptom,    the 
5  65 


INAUGURAL  SYMPTOMS. 


thrice-repeated  rigor,  was  at  once  appreciated  when 
the  pathological  condition  was  exposed,  for  the  initial 
rigors  were  clearly  due  to  an  acute  inflammatory  proc- 
ess in  the  walls  of  the  uterus,  while  the  later  perfora- 
tion into  the  general  peritoneum  was  announced  by  the 
sudden  onset  of  the  very  severe  abdominal  pain. 

Time  permits  me  to  refer  only  in  the  briefest  manner 
to  the  pancreas.  This  is  the  most  important  gland  in 
the  human  economy;  of  its  diseases  we  know  little, 
and  of  their  inaugural  symptoms  nothing  at  all.  Yet 
it  is  hardly  possible  that  a  gland  whose  external  secre- 
tion is  the  most  potent  of  all  digestive  juices,  and  whose 
internal  secretion  is  deeply  concerned  with  the  regula- 
tion of  the  metabolic  processes  of  the  body,  should  be 
able  to  deviate  widely  from  the  normal  without  be- 
traying some  clear  sign.  Many  of  the  disorders  of  the 
pancreas,  as  Riedel  taught  us  long  ago,  are  associated 
with  cholelithiasis.  Mayo  Robson  has  recently  put 
forward  good  reasons  for  supposing  that  "catarrhal 
jaundice"  may  be  due  to  an  inflammation  of  the  pan- 
creas, whose  consequent  enlargement  causes  pressure 
upon  and  obstruction  within  the  duct,  which  it  trans- 
mits to  the  duodenum.  I  think  the  better  view  may  be 
that  both  gall-stones  and  pancreatitis  are  themselves 
the  result  of  an  infection  of  the  bile  as  it  descends  from 
the  liver.     The  scavenging  properties  of  the  bile  have 

66 


INAUGURAL  SYMPTOMS. 


been  demonstrated  by  Lartigau  and  others.  This 
excretion  bears  away  certain  organisms  brought  to  the 
liver  in  the  portal  stream,  organisms  which  render  it 
an  infective  agent,  which  dispose  to  the  formation  of 
stones,  and  which  make  possible  the  infliction  of  an 
injury  to  the  pancreas.  Of  the  significance  and  of  the 
consequence  of  inflammation  so  set  going  we  are  only 
now  beginning  to  realize  the  grave  importance.  In 
two  cases  in  my  own  practice  I  have  kno"v^Ti  of  deaths 
from  diabetes  three  years  and  six  years  after  operation 
at  which  chronic  pancreatitis  was  discovered.  We 
now  know,  chiefly  from  the  work  of  Opie,  that  in  a 
certain  form  of  pancreatitis,  the  interacinar,  the  islands 
of  Langerhans  are  attacked,  their  internal  secretion 
which  controls  carbohydrate  metabolism  is  suppressed, 
and  diabetes  results.  But  we  have  very  little  knowl- 
edge of  the  frequency  with  which  diabetes  depends 
upon  a  lesion  of  the  pancreas,  nor  do  w^e  know  how  often 
such  a  lesion  can  be  traced  to  an  attack  of  "catarrhal 
jaundice"  passed  through  in  the  days  of  infancy  or 
childhood.  Happily  the  labours  of  Cammidge  have 
now  made  it  possible  for  us  to  recognise,  by  examina- 
tion of  the  urine  and  faeces,  whether  a  morbid  condition 
of  the  pancreas  is  present  in  any  given  case.  We  know 
that  in  mumps  the  gland  is  not  seldom  attacked, 
its  impUcation  in  typhoid  fever,  as  I  have  shown,®  is 

67 


INAUGURAL  SYMPTOMS. 


capable  of  demonstration,  and  it  seems  not  improbable 
that  it  is  in  some  degree  affected  in  many  of  the  acute 
specific  fevers.  What  relation,  if  any,  such  incidents 
bear  to  the  later  onset  of  diabetes  we  have  no  remotest 
idea;  but  the  subject  may  well  repay  attentive  in- 
quiry. The  inaugural  disturbances  in  so  important  a 
gland  as  the  pancreas  may  perhaps  have  consequences 
the  vastness  and  the  importance  of  which  are  hardly 
realised  to-day. 

These  are  some  of  the  instances,  not  by  any  means 
all,  perhaps  not  even  the  happiest,  which  might  have 
been  selected,  in  which  a  commencement  has  been 
made  in  the  investigation  of  the  inaugural  symptoms  of 
abdominal  diseases.  It  has  seemed  to  me  desirable 
and  appropriate  to  call  attention  to  the  necessity  for  a 
closer  and  more  intimate  study  of  all  diseases  in  their 
earliest  beginnings.  We  must  shake  off  the  incurious 
apathy  which  seems  now  to  possess  us  in  reference 
to  all  those  early,  no  doubt  often  'trivial,"  disturbances 
of  health  which  lead  slowly  or  swiftly,  none  the  less 
surely,  to  disorders  of  so  grave  a  character  that  serious 
or  formidable  measures  become  necessary  for  their 
arrest.  It  is  chiefly,  I  think,  to  the  general  practitioner 
that  we  must  look  for  the  most  effective  help  in  this 
research.  It  is  he  who  sees  the  cases  first,  and  it  is  he 
to  whom  the  occasion  and  the  opportunity  come  for 

68 


INAUGURAL  SYMPTOMS. 


the  early  diagnosis.  I  believe  it  to  be  true  that  our 
text-book  descriptions  of  the  clinical  aspects  of  many 
diseases  are  based  upon  the  manifestations  which  are 
present  when  that  disease  is  in  its  full  career  or  is 
hastening  to  the  end.  The  terminal  rather  than  the  pro- 
dromal symptoms  receive  detailed  description.  This 
was,  of  course,  inevitable  in  the  days  when  the  con- 
firmation of  the  diagnosis  could  only  be  made  at  the 
time  the  dead  body  was  examined.  Now  our  oppor- 
tunity is  greater  and  our  responsibility  clearer.  It  is, 
I  think,  by  a  closer  and  more  intimate  examination  of 
the  anamnesis,  followed  by  a  precise  investigation  of 
the  parts  affected  during  the  life  of  the  patient,  that 
our  knowledge  of  the  earlier  phases  of  diseases  will 
come.  By  this  means  we  shall  be  able  by  degrees  to 
remove  the  reproach  that  now  justly  attaches  to  much 
of  our  work  in  the  surgery  of  the  abdominal  viscera — 
the  reproach  that  we  are  so  often  ''too  late." 

REFERENCES. 

1.  British  Medical  Journal,  1907,  ii,  p.  1381. 

2.  Practitioner,  July,  1907. 

3.  Prag.  med.  Woch.,  1884,  49. 

4.  Annals  of  Surgery,  1908,  xlvii,  889. 

5.  British  Medical  Journal,  1906,  i,  p.  370. 

6.  Surgery,  Gynaecology  and  Obstetrics,  1908,  i,  p.  463. 

7.  See    Gaston   Torrance,  Jour.    Amer.  Med.  Assoc,  1908, 
ii,  p.  127. 

8.  Lancet,  1903,  i,  p.  1586. 

69 


AN  ADDRESS 

ON 

Gastro-enterostomy  and  After.* 

On  September  27,  1881,  Wolfler,  then  assistant  to 
Billroth,  in  Vienna,  was  engaged  in  operating  upon  a 
patient  suffering  from  carcinoma  of  the  pyloric  portion 
of  the  stomach.     Resection,  which  it  was  the  intention 
of  the  operator  to  perform,  was  found  to  be  impossible, 
and  the  abdomen  was  about  to  be  closed  when  Nicola- 
doni,  who  was  acting  as  assistant,  suggested  that  a  new 
outlet  from  the  stomach,  to  replace  that  which  the 
disease  had  obstructed,  might  be  made  by  attaching 
the  jejunum  to  the  stomach.     There  are  few  surgeons 
who  can  afford  to  neglect  the  whispered  hint  of  a  well- 
trained  and  familiar  assistant,  and  Wolfler  immediately 
acted  upon  the  suggestion  thus  quietly  made  to  him. 
In  this  way  there  was  introduced  to  surgery  an  opera- 
tion which  has  been  the  means  of  saving  unnumbered 
lives,  and  of  restoring  to  many  thousands  that  enjoy- 
ment of  perfect  health  which  would  otherwise  have  been 

*  Reprinted  from  British  Medical  Journal,  May  9,  1908. 

71 


GASTROENTEROSTOMY  AND  AFTER. 

forever  denied  them.  In  surgical  work  the  perfect 
method  is  rarely,  if  ever,  a  matter  of  instant  accom- 
plishment, nor  is  it  often  the  work  of  a  single  individual. 
The  very  great  majority  of  the  operations  practised 
to-day  are,  so  to  speak,  composite  procedures  made  up 
of  details  suggested  here  by  one  authority,  there  by 
another. 

In  the  constant  endeavour  to  find  the  simple  and 
the  safe  method  of  gastro-enterostomy  mechanical 
aids,  almost  beyond  computation  in  their  infinite 
variety,  have  been  exploited  by  one  surgeon  after 
another.  Happily,  we  have  at  last  arrived  with  con- 
fidence at  the  conclusion  that  nothing  more  is  necessary 
to  ensure  the  firm  union  of  the  intestine  to  the  stomach 
than  the  simple  continuous  suture.  But  though  these 
bobbins,  buttons,  elastic  ligature,  and  strings  of  all 
kinds  are  relegated  forever  to  the  museum  shelves,  we 
owe  it  to  their  inventors,  and,  above  all,  to  Dr.  J.  B. 
Murphy,  to  say  that,  without  the  knowledge  and  the 
confidence  which  these  things  generally  have  given 
us,  the  progress  of  intestinal  surgery  must  have  been 
long  delayed. 

In  the  original  operation  of  Wolfler  the  jejunum  was 
attached  to  the  anterior  surface  of  the  stomach,  and 
it  was  placed  in  such  a  manner  that  its  proximal  end 
lay  to  the  right,  its  distal  to  the  left.     The  jejunum, 

72 


GASTROENTEROSTOMY  AND  AFTER. 

that  is  to  say,  was  anti-peristaltic  in  relation  to  the 
stomach.  Various  disabilities,  the  chief  of  which  was 
regurgitant  vomiting,  followed  this  operation,  and  in 
1885  von  Hacker  attempted  to  overcome  them  by 
utilising  the  posterior  surface  of  the  stomach  rather 
than  the  anterior  for  the  anastomosis.  The  results  at 
first  were  little,  if  at  all,  better,  and  it  was  not  until 
the  year  1900  that  the  real  causes  of  the  distressing 
complications  of  the  operation  began  to  be  understood. 
In  that  year  Petersen,  in  reporting  the  results  of  Czerny's 
clinic  at  Heidelberg,  called  attention  to  the  need  for 
the  attachment  of  the  jejunum  to  the  stomach  at  a 
point  as  close  to  the  flexure  as  possible.  He  gave  good 
reasons  for  the  adoption  of  the  ''no  loop'^  method, 
and  by  degrees  the  opinion  has  become  widespread, 
if  not  general,  that  the  posterior  no-loop  operation 
gives  results,  both  immediate  and  remote,  which  are 
decidedly  more  satisfactory  than  those  attainable  by 
any  other  method.  In  this  operation,  as  I  described 
it  some  years  ago,  the  attachment  of  the  jejunum  to 
the  stomach  was  made  along  a  line  which  ran  from 
above  downwards  and  to  the  right,  to  end  at  the  lowest 
point  of  the  greater  curvature.  In  my  own  hands  this 
operation  gave  excellent  results;  but  this  experience 
was  not  repeated  by  all  surgeons.  Dr.  W.  J.  Mayo,  for 
example,  found  that  in  some  instances,  generally  after  a 

73 


GASTRO-ENTEROSTOMY  AND  AFTER. 

period  of  a  few  weeks  or  a  few  months,  bilious  vomiting 
became  troublesome,  and  in  certain  cases  necessitated 
a  secondary  operation.  He  considered  that  this  symp- 
tom was  due  to  a  mechanical  obstruction,  a  kinking  of 
the  jejunum  either  at  the  flexure  or  at  the  upper  end 
of  the  attachment  of  the  bowel  to  the  stomach,  due  to 
a  double  displacement  of  the  intestine  from  its  normal 
position.     The  normal  position  he  described  thus:^ 

The  jejunum  from  its  origin  drops  at  once  into  the 
left  abdominal  fossa.  Not  only  does  it  pass  to  the 
left,  but  it  gravitates  backwards  into  the  left  kidney 
pouch  underneath  the  splenic  flexure  of  the  colon,  so 
that  at  a  point  4  inches  from  its  origin  it  lies  on  a  plane 
to  the  left  and  posterior. 

Accordingly  he  suggested  that  the  attachment  of  the 
jejunum  to  the  stomach  should  be  made  in  such  manner 
as  not  to  alter  this  ''normal  position.'^  The  opening 
in  the  stomach  was  therefore  made  to  run  from  above 
downwards  and  to  the  left. 

There  can  be  no  doubt  that  the  position  Dr.  Mayo 
describes  is  that  in  which  the  jejunum  is  often  (by  no 
means  always)  found  when  the  abdomen  is  opened 
upon  the  operation  or  post-mortem  tables.  And  it 
is  so  found  for  a  very  good  reason — that  is  the  position 
into  which  it  falls  by  gravity  when  the  patient  lies  on 
the  back .    The  duodenum  ends  and  the  j  e j  unum  begins 

74 


GASTRO-ENTEROSTOMY  AND  AFTER. 


on  the  left  side  of  the  front  of  the  body  of  the  second 
lumbar  vertebra,   and  from  here,   in  the  recumbent 
position  of  a  patient,  the  gut,  if  free  to  move,  will 
naturally    drop    backwards    into    the   kidney   pouch. 
But  a  moment's  consideration  will  make  it  clear  that 
this  can  be  no  fixed  position.     The  jejunum  is  pendent 
from  the  flexure  and  alters  its  position  from  time  to 
time;    it  can  swing  from  one  side  to  the  other  with 
ease,  and  without  obstruction  occurring  at  the  flexure. 
The  little  mesocoHc  ligament  prevents  it  sagging  too 
tightly  down  towards  the  pelvis.     I  think  it  probable 
that  this  slender  ligament  exists  purely  for  the  purpose 
of  suspending  the  flexure  in  order  to  prevent  a  kink 
occurring  in  any  of  the  various  movements  of  the  gut. 
If  a  patient  be  made  to  lie  on  the  right  side  before  the 
abdomen  is  opened  the  jejunum  will  be  found  to  fall 
to  the  right.     If  a  patient  dies  while  lying  on  the  right 
side,  the  jejunum  will  be  found  to  pass  almost  horizon- 
tally to  the  right,  as  I  have  clearly  demonstrated. 
There  can  be  no  ''normal  position,"  therefore,  of  the 
jejunum  in  the  sense  described.     The  jejunal  origin  is 
so  constructed  that  an  easy  play  of  the  gut  in  all  direc- 
tions is  possible.     The  best  position,  therefore,  for  an 
anastomosis  of  the  jejunum  with  the  stomach  to  take 
is  determined  by  the  most  frequent  or  easiest  position 
taken  naturally  by  the  jejunum.     This  is,  in  my  opin- 

75 


GASTRO-ENTEROSTOMY  AND  AFTER. 

ion,  the  vertical  position;  and  for  some  time  now  I  have 
attached  the  bowel  as  nearly  as  possible  in  the  exact 
median  vertical  plane,  and  have  made  the  anastomosis 
as  close  to  the  flexure  as  possible.  In  a  paper  elsewhere 
I  have  discussed  the  causes  of  the  *' bilious  vomiting" 
which  occurs  after  the  "no-loop"  operation;  here  I 
need  only  say  that  it  is  probably  due  to  a  mechanical 
obstruction,  slight  indeed  and  perhaps  intermittent, 
caused  by  a  partial  rotation  of  the  gut  around  its 
longitudinal  axis  at  the  time  the  attachment  to  the 
stomach  is  made.  It  is  therefore  necessary  to  see  that 
the  part  of  the  jejunum  selected  for  the  suture  lines 
can  be  approximated  easily,  and  without  a  twist  or 
kink,  to  the  posterior  surface  of  the  stomach  at  the 
place  where  the  attachment  is  to  be  made.  This, 
then,  is  the  method  of  gastro-enterostomy  which  I 
believe  to  be  the  best;  it  is  that  which  I  have  practised 
for  almost  four  years  in  all  cases,  except  in  some  few 
instances,  about  twenty  or  thirty  in  all,  in  which  I  have 
performed  the  anastomosis  along  Mayo's  line.  The 
immediate  mortality  of  the  operation  has  varied  ac- 
cording to  the  type  of  case  for  which  it  is  done.  If 
cases  of  perforation  and  acute  haemorrhage  are  excluded 
the  mortality  is  less  than  1  per  cent.  In  cases  of 
chronic  duodenal  ulcer  it  has  been  in  my  hands  a  little 
over  2  per  cent.     I  have  had  no  deaths  among  the 

76 


GASTROENTEROSTOMY  AND  AFTER. 

cases  of  chronic  gastric  ulcer.  When  the  very  en- 
feebled condition  of  many  of  the  patients  is  remem- 
bered, I  think  it  will  be  conceded  that  a  smaller  mortal- 
ity than  this  is  hardly  to  be  expected  in  an  operation 
of  this  character.  The  immediate  results  of  gastro- 
enterostomy thus  performed  are,  then,  quite  satis- 
factory. What  are  the  ultimate  results?  Before  en- 
deavouring to  give  a  satisfactory  reply  to  this  most 
important  question  I  would  ask  you  first  to  consider 
what  manner  of  operation  gastro-enterostomy  is,  and 
what  is  the  precise  purpose  we  should  expect  it  to  fulfil. 
I  am  an  ardent  and  a  sanguine  advocate  of  this  opera- 
tion, than  which  I  think  there  is  none  in  all  surgery 
more  completely  satisfactory;  but  I  must  confess 
to  a  feeling  of  amazement,  when  I  see  the  opera- 
tion advocated,  as  it  not  seldom  is,  for  conditions 
for  which  hardly  anything  could  be  more  inappro- 
priate. 

Gastro-enterostomy  is,  of  course,  a  ''short-circuiting 
operation,'^  so  called.  It  affords  an  opportunity  to  the 
stomach  contents  to  avoid  the  long  passage  by  the 
pylorus  and  duodenum  into  the  jejunum.  Do  the 
contents  avail  themselves  of  this  chance?  This  ques- 
tion raises  the  further  question  as  to  the  effect  of  short- 
circuiting  operations  in  general  in  the  alimentary  canal. 
Supposing  antero-anastomosis  to  be  performed,  does 

77 


GASTROENTEROSTOMY  AND  AFTER. 

the  opening  encourage  all  or  any  of  the  contents  to 
pass  by  the  new  route,  or  is  the  old  route  more  easily 
followed?  This  question  has  been  answered  both  by 
clinical  and  by  experimental  work.  For  example,  in 
a  case  of  acute  general  peritonitis  due  to  gangrenous 
appendicitis  upon  which  I  operated  twelve  months  ago, 
a  faecal  fistula  followed  and  refused  to  heal.  I  there- 
fore decided  to  operate,  and,  making  an  incision  over 
the  sigmoid  flexure,  I  anastomosed  the  lowest  piece  of 
small  intestine  available  above  the  fistulous  opening 
to  the  sigmoid,  the  new  opening  being  about  3  inches 
in  length.  After  the  operation  the  fsecal  fistula  dis- 
charged for  several  weeks,  exactly  as  it  had  done  before, 
and  continued  to  do  so  until  I  obliterated  the  part 
distal  to  the  anastomosis  by  suture.  This  case  exempli- 
fies what  I  believe  to  be  a  fact — that  artificial  openings 
are  not  preferred  to  the  natural  channels,  unless  in  the 
course  of  the  latter  some  obstruction  is  present.  A 
great  deal  of  valuable  experimental  work  has  been  done 
by  several  observers,  the  first  of  whom  was  Kelling.^ 
In  a  long  series  of  investigations  he  performed  gastro- 
enterostomy by  all  methods — anterior,  posterior, 
Roux's;  attaching  the  jejunum  at  a  high  point,  at  a 
low,  and  the  ileum  at  any  part.  The  results  were 
always  the  same.  Nothing  passed  by  the  new  anasto- 
mosis;  all  food,  solid  or  liquid,  went  through  the  py- 

78 


GASTRO-ENTEROSTOMY  AND  AFTER. 

lorus.  Cannon  and  Blake-'  demonstrated  the  same 
facts.  When  the  jejunum  was  joined  to  the  stomach, 
the  new  opening  was  not  made  use  of,  except  in  one 
case  where  it  lay  very  close  to  the  pylorus,  and  then 
only  in  a  small  measure.  Delbet^  divided  the  intes- 
tines and  attached  the  distal  end  to  the  stomach  and 
the  upper  to  the  skin,  so  that  all  food  passing  by  the 
gastro-enterostomy  opening  would  be  discharged  by 
the  rectum,  all  leaving  by  the  pylorus  would  escape  at 
the  artificial  anus.  Nothing  ever  passed  through  the 
anastomosis;  everything  ingested,  fluid  or  solid,  left 
by  the  pylorus,  and  was  discharged  on  the  surface  of 
the  abdomen. 

Tuffier^  showed  the  truth  of  these  observations  in 
similar  experiments,  when  the  working  of  the  parts  was 
demonstrated  by  feeding  the  animals  with  food  con- 
taining bismuth.  In  all  cases  and  in  the  hands  of  all 
observers  the  same  fact  was  disclosed:  with  an  un- 
obstructed pylorus  nothing  is  ever  transmitted  through 
a  gastro-enterostomy  opening.  Why  is  this?  The 
explanation  given  by  Cannon  and  Blake  is  probably 
correct;  it  is  that  the  new  orifice  becomes  stretched  in 
the  movements  of  the  stomach,  and  so  becomes,  as  it 
were,  a  part  of  the  gastric  wall,  not  the  slightest  aper- 
ture remaining. 

Much  of  the  literature  dealing  with  the  surgery  of 

79 


GASTRO-ENTEROSTOMY  AND  AFTER. 

the  stomach  has  been  hitherto  concerned  with  the  de- 
tails of  technique,  with  the  comphcations  which  follow 
immediately  upon  the  operation,  and  with  the  mortal- 
ity. Upon  all  these  points  there  is  now  very  little 
left  to  say,  except  with  regard  to  a  very  formidable 
sequel,  destined,  I  believe,  to  prove  the  most  serious  of 
all — namely,  peptic  ulcer  of  the  jejunum.  Almost 
nothing  has  been  written  as  to  the  after-results  of  the 
operation,  and,  so  far  as  my  knowledge  goes,  there  has 
been  no  close  examination  into  the  history  of  patients 
at  some  long  period  after  operation,  nor  any  considered 
opinion  passed  upon  the  information  so  discovered. 
Of  the  immediate  success  of  gastro-enterostomy  and 
of  its  small  death-rate  many  surgeons  can  now  speak 
with  the  authority  of  adequate  experience.  But  there 
is  great  need  for  a  close  scrutiny  of  late  results,  in  order 
that  we  may  learn  what  disabilities  may  attach  to  the 
operation,  what  are  the  limits  to  be  put  to  its  perform- 
ance, what  exactly  are  its  sustained  effects  upon  the 
general  nutrition,  and,  finally,  whether  there  is  a 
possibility  of  any  recurrence  in  the  stomach  or  in  the 
duodenum  of  whatever  disorders  first  made  the  opera- 
tion imperative. 

In  order  to  be  able  to  speak  with  some  authority 
upon  these  points,  I  have  collected  the  records  of  all 
cases  operated  upon  by  me  up  to  the  end  of  the  year 

80 


GASTROENTEROSTOMY  AND  AFTER. 

1905.  Owing  to  the  kindness  and  courtesy  of  the  many 
medical  men  who  referred  the  patients  to  me  in  the  first 
instance,  I  have  been  enabled  to  obtain  written  answers 
to  a  series  of  printed  questions  as  to  the  present  con- 
dition (February,  1908)  of  most  of  them.  The  reports 
in  the  great  majority  of  cases  have  been  made  by  the 
medical  men,  but  a  few  have  been  received  direct  from 
the  patients  themselves.  In  order  to  eliminate  all 
prejudice  these  reports  were  then  handed  over  to  my 
colleague,  Mr.  H.  CoUinson,  who  very  kindly  under- 
took the  heavy  task  of  summary,  analysis,  and  criti- 
cism. For  convenience  and  to  ensure  greater  accuracy 
the  cases  were  divided  into  four  groups,  in  accordance 
with  the  plan  always  followed  by  me : 

NuMBEE  OF     Number  of 
Cases  Deaths 

(1)  Perforating  ulcer 9  1 

(2)  Cases  of  acute  haemorrhage 26  3 

(3)  Cases  of  chronic  ulcer 205  2 

(4)  Cases  of  hour-glass  stomach 15  3 

Total 255  9 

In  all,  there  were  accordingly  255  cases  with  9 
deaths,  a  mortality  of  3.5  per  cent.  But  in  order  to 
assess  the  actual  risk  which  a  patient  undergoes  it  is 
more  accurate  to  compute  the  death-rate  in  each 
separate  class;  for  in  cases  where  the  operation  was 
done  because  death  was  imminent  from  haemorrhage 
6  81 


GASTROENTEROSTOMY  AND  AFTER. 

the  risk  must  obviously  be  greater,  and  in  the  cases  of 
hour-glass  stomach  gastro-enterostomy  may  be  only 
one-half  the  operation  necessary;  in  no  less  than  6  of 
the  15  cases  in  my  series  has  gastro-gastrostomy  or 
gastroplasty  to  be  performed  at  the  same  time.  These 
complications  add  perhaps  a  greater  increment  of  risk 
than  does  strangulation  to  the  ordinary  operation  of 
radical  cure  of  a  hernia.  In  my  series  of  cases,  from 
the  first  I  performed  up  to  March,  1906,  including 
every  case  and  all  complications,  the  mortality  is  under 
2  per  cent.  But  mere  recovery  from  an  operation  is 
by  no  means  all  that  is  necessary.  There  is  an  unfor- 
tunate habit  of  describing  an  operation  as  ''successful" 
almost  at  the  moment  of  its  completion.  We  are  all 
accustomed  to  be  asked  by  the  relatives  of  patients  who 
are  interviewed  when  an  operation  is  immediately  over, 
whether  the  operation  has  been  "successful."  That  is 
a  question  which  may  be  answered  satisfactorily  only 
after  the  lapse  of  many  months.  In  an  operation  of 
the  severity  of  gastro-enterostomy — an  operation, 
moreover,  by  which  certain  physiological  principles 
seem  to  be  set  at  naught — the  lapse  of  two  years  is 
certainly  not  too  much  to  allow  us  to  speak  with  con- 
fidence as  to  its  success.  I  propose  to  consider  the 
after-results  of  my  cases  in  the  following  manner: 


82 


gastro-entp:rostomy  and  after. 

Group  1. — Perforation  of  the  Stomach  or  Duo- 
denum. 

During  the  period  mentioned,  that  is,  to  the  end  of 
1905,  I  operated  upon  27  cases  of  perforating  ulcer; 
18  patients  recovered.  In  6  cases  gastro-enterostomy 
was  performed  immediately  after  the  closing  of  the 
ulcer,  because  of  the  narrowing  at  or  near  the  outlet  of 
the  stomach  which  this  procedure  had  caused.  In  two 
other  patients  symptoms  due  to  cicatricial  stenosis 
near  the  pylorus  developed  within  a  few  months,  and 
gastro-enterostomy  was  necessary  to  afford  relief.  In 
one  patient  I  have  recently  had  to  operate  four  years 
after  the  closure  of  a  perforating  ulcer,  which  had 
caused  a  contraction  in  the  centre  of  the  stomach. 
Gastro-enterostomy  was  performed  to  the  greatly 
hypertrophied  cardiac  pouch  of  an  hour-glass  stomach. 
In  9  cases,  therefore,  in  a  total  of  18  who  recovered,  the 
operation  of  gastro-enterostomy  has  been  necessary. 
All  these  cases  are  reported  to  be  now  quite  well.  Of 
the  remaining  9  cases,  8  are  quite  well  and  are  free  from 
stomach  symptoms,  one  suffers  from  slight  indigestion 
and  occasional  vomiting;  the  ulcer  in  this  case  was 
prepyloric.  The  freedom  from  suffering  of  those  pa- 
tients in  whom  the  ulcer  was  on  the  lesser  curvature 
and  away  from  the  pylorus  is  significant  in  connexion 

83 


GASTRO-ENTEROSTOMY  AND  AFTER. 

with  the  question  as  to  the  need  for  gastro-enterostomy 
in  cases  of  chronic  ulcer  so  placed.  Infolding  or  the 
excision  of  such  an  ulcer,  it  is  clear,  suffices  to  efTect 
a  cure. 

Group  2. — Acute  Hemorrhage. 
In  the  series  of  haemorrhage  cases  there  are  23  pa- 
tients who  recovered  from  the  operation.  All  are  alive 
now,  and  reports  as  to  the  present  state  of  health  have 
been  received  from  22.  One  patient,  who  was  ad- 
mitted to  the  hospital  from  prison,  cannot  now  be 
traced;  18  are  reported  as  being  ^'perfectly  well," 
''cured,"  ''absolutely  cured";  in  each  one  a  complete 
restoration  to  health,  good  digestion,  and  normal 
appetite  has  occurred.  One  case  is  improved  in  health, 
but  is  rather  delicate.  His  medical  man  reports  "the 
operation  was  for  urgent  and  grave  haematemesis,  and 
undoubtedly  saved  the  patient's  life,  but  he  is  still  as 
he  was  before — weak  and  frail.  There  are  no  symptoms 
of  dyspepsia."  Three  patients  have  suffered  from 
post-operative  vomiting.  Two  of  the  cases,  operated 
upon  in  January  and  March,  1903,  had  the  posterior 
long-loop  operation;  in  one  vomiting  of  bile  occurred 
infrequently  for  a  year  and  then  disappeared.  The 
patient  is  now  "quite  well."  In  another  it  has  con- 
tinued at  intervals  of  two  up  to  three  weeks  up  to  the 

84 


GASTROENTEROSTOMY  AND  Al^^ER. 


present  time;   the  patient,  moreover,  says  that  she  is 
''far  better"  than  before,  and  "able  to  work  now." 
In  the  third  case  the  no-loop  operation  was  performed, 
the  jejunal  direction  being  downwards  and  to  the  right. 
This  case  is  to  me  the  most  interesting  of  all,  for  it  is 
the  only  case  in  which  after  the  no-loop  operation  any 
bilious  vomiting  has  occurred.     The  operation  was  in 
February,  1905,  upon  a  patient  seen  ^dth  Dr.  Nicholson 
Dobie  and  the  late  Dr.  Dreschfeld.     BiHous  vomiting 
occurred  every  week  or  two  up  to  three  months  ago, 
when  it  disappeared  after  repeated  lavage.   In  this  case, 
after  the  anastomosis  was  completed,  it  was  noticed 
that  the  jejunum  did  not  fit  well;    it  seemed  to  be 
twisted  above  the  point  of  union  with  the  stomach: 
a  remark  to  this  effect  is  made  in  the  notes  written  on 
the  day  of  operation.     In  over  200  cases  of  the  posterior 
no-loop  operation  in  which  the  jejunum  was  applied  to 
the  stomach  vertically  or  with  a  slight  inclination  to  the 
right,  this  is  the  only  one  in  which  bilious  vomiting  has 
occurred,  and  it  is  of  great  interest  to  note  the  fact  that 
the  appearance  of  the  parts  at  the  completion  of  the  op- 
eration did  not  seem  to  me  to  be  as  satisfactory  as  usual 

Group  3.— Chronic  Gastric  or  Duodenal  Ulcer. 

There  were  205  patients,  upon  whom  214  operations 

were  performed. 

85 


GASTROENTEROSTOMY  AND  AFTER. 

The  following  table  shows  the  cases  classified: 

Cases    Deaths 

(a)  Gastric  ulcer,  duodenal  ulcer — singly  or  together  174  2 

(6)   Cholelithiasis  with  ulcer 4  0 

(c)  Cholelithiasis  causing  obstruction 6  0 

(d)  Cases  in  which  no  ulcer  was  found 11  0 

(e)  Pyloroplasty   (secondary  gastro-enterostomy) .  .       3  0 
(J')   Secondary  operations,   the  primary  being  per- 
formed elsewhere 7  0 

(g)  Secondary  operations  in  cases  classed  under  (a) 

and(/) 9        0 

214        2 

Late  Results. 

In  14  cases  no  report  was  furnished  in  1908,  but  in 
11  of  these  the  patients  were  seen  by  me  or  reports  were 
received  over  two  years  after  operation,  and  I  have 
notes  to  say  that  all  were  well;  in  3  cases  no  report 
can  be  obtained. 

In  12  cases  the  patients  were  reported  to  be  "no 
better"  or  "about  the  same."  In  6  of  these  cases,  all 
women,  no  ulcer  was  found  at  the  operation,  nor  any 
evidence  of  obstruction.*  One  of  the  cases  was  a 
secondary  operation  by  myself,  the  primary  operation 
having  been  performed  elsewhere.  I  found  no  lesion 
of  the  stomach,  and  closed  the  abdomen  without  doing 

*It  is  now  clear  to  me  that  these  were  cases  of  "appendix 
dyspepsia";  a  class  of  cases  now  easily  to  be  recognised.  The 
medical  "gastric  ulcer"  is  frequently  an  appendix. 

86 


GASTRO-ENTEROSTOMY  AND  AFTER. 


anything  further.  There  has  been  no  relief  from  the 
symptoms,  pain,  and  hsematemesis.  In  another  case 
the  lesion  was  very  slight,  a  small  scar  only  being  found 
on  the  posterior  surface.  One  case  is  an  example  of 
Finney's  operation.  Three  suffer  from  regurgitant 
vomiting,  but  are  kept  fairly  comfortable  and  free  from 
symptoms  by  lavage. 

A  close  study  of  the  unsatisfactory  cases  has  seemed 
to  me  to  be  especially  necessary,  in  order  to  discover  the 
circumstances  in  which  the  operation  of  gastro-enter- 
ostomy  does  not  give  satisfactory  results.  All  the 
patients  had  suffered  much  from  "indigestion,"  pain 
of  sufficient  severity  to  make  them  consider  hopefully 
the  question  of  operation,  and  from  vomiting,  h^mate- 
mesis  in  2  cases,  and  loss  of  weight.  Nine  of  the  pa- 
tients were  women.  Of  the  3  cases  in  men,  2  were 
relieved  entirely  of  their  original  symptoms,  but  suffer 
from  regurgitant  vomiting;  both  operations  were 
performed  in  1903,  and  a  long  jejunal  loop  was  left; 
the  third  was  a  case  of  Finney's  operation.  Among 
the  9  women  there  were  6  in  whom  no  ulcer  could  be 
demonstrated;  and  there  was  neither  stasis  nor  evi- 
dent obstruction  in  any  of  them.  Three  of  the  pa- 
tients are  pronounced  to  be  ** intensely  neurotic,"  and 
the  operation  has  "not  made  much  difference."  It  is 
satisfactory  to  be  able  to  report  that  only  one  case  in 

87 


GASTROENTEROSTOMY  AND  AFTER. 


this  series  was  operated  upon  later  than  January,  1904. 
The  lessons  to  be  learnt  from  this  series  are :  That  the 
mimicry  of  the  symptoms  of  ulcer  in  women  may  be 
very  exact;  that  in  the  absence  of  a  demonstrable 
lesion,  or  some  evidence  of  stenosis,  gastro-enterostomy 
must  not  be  performed;  that  the  long  jejunal  loop  is 
the  cause  of  regurgitant  vomiting;  and  that  rehef  to 
symptoms  may  be  completely  given  by  an  operation 
which  is  mechanically  imperfect,  and  which  therefore 
entails  that  distressing  sequel,  bilious  vomiting. 

In  5  cases  there  has  been  complete  relief  from  the 
symptoms  for  which  the  operation  was  done,  but  in  all 
there  is  slight,  very  occasional  vomiting  of  bile.  The 
intervals  of  this  vary  from  ''two  to  three  weeks"  to 
''every  few  months."  In  all,  the  patients  have  re- 
turned to  work,  eat  well,  have  gained  weight,  and 
attribute  the  onset  of  the  vomiting  to  slight  or  grave 
indiscretions  in  the  matter  of  diet.  In  4  of  the  cases 
the  patients  are  "well  satisfied"  with  the  result  of  the 
operation,  though  their  surgeon  does  not  share  their 
feeling  of  content. 

In  10  cases  the  improvement  is  doubtful  or  has  been 
tardy;  3  of  these  were  secondary  operations,  the  origi- 
nal operation  being  done  elsewhere.  In  one  case  of 
duodenal  ulcer  with  the  most  intense  hyperchlorhydria 
there  was  a  recurrence  of  symptoms  one  year  later,  and 

88 


GASTROENTEROSTOMY  AND  AFTER. 

at  a  second  operation  elsewhere  some  adhesions  and  a 
jejunal  ulcer  (?)  were  found.  The  patient  recovered 
and  improved  subsequently.  One  patient,  after  im- 
proving considerably,  began  to  suffer,  subsequent  to 
pregnancy,  from  severe  dragging  pain  in  the  abdomen. 
Ventrifixation  of  the  uterus  was  performed,  and  she  is 
now  well  and  at  work.  The  remaining  patients  have 
still  some  of  their  former  symptoms,  and  usually  have 
to  make  occasional  calls  upon  their  medical  men.  The 
chief  symptom  that  remains  is  vomiting.  In  all,  the 
ulcer  found  was  small,  and  at  some  distance  from  the 
pylorus,  in  the  body  or  on  the  lesser  curvature  of  the 
stomach. 

Eight  patients  have  died  since  the  operation:  one, 
six  and  a  half  years  later  of  carcinoma  of  the  pancreas; 
one,  six  years  later  after  operation  by  another  surgeon 
for  carcinoma  of  the  caecum;  one,  eight  months  later 
of  acute  pneumonia;  one,  four  years  later  of  cardiac 
disease;  one,  three  months  later  of  acute  abscess  of 
lung;  one,  one  year  later  of  cardiac  disease;  one,  two 
years  later  of  pernicious  anaemia;  in  one  case  the  cause 
of  death  three  years  later  is  not  mentioned. 

In  7  cases  death  occurred  from  malignant  disease 
of  the  stomach  developing  at  the  site  of  the  ulcer. 
The  deaths  occurred  two  years,  four  years,  two  and  a 
half  years,  three  and  a  quarter  years,  one  year,  one  and 

89 


GASTROENTEROSTOMY  AND  AFTER. 

a  half  years  and  two  and  a  half  years  subsequently. 
The  deaths  in  these  cases  are  very  significant.  The 
interval  in  most  of  them  between  operation  and  death 
suggests  that  the  condition  present  at  the  time  of  the 
operation  was  not  then  malignant,  but  rather  that  a  car- 
cinomatous invasion  of  the  diseased  part  occurred  at  a 
later  period.  They  were,  perhaps,  examples  of  ulcus 
carcinomatosum.  There  can  be  no  doubt  that  in  some  of 
these  cases  Rodman's  operation — excision  of  the  ulcer- 
bearing  area — would  have  been  the  better  procedure. 

Two  patients  died  as  a  direct  result  of  the  operation : 
one  from  uraemia,  one  from  acute  obstruction  due  to 
hernia  of  all  the  small  intestines  into  the  lesser  sac,  and 
strangulation  at  the  margin  of  the  opening  through  the 
transverse  mesocolon. 

The  final  results  in  this  group  may  be  briefly  stated 
thus: 

LixYing: 

Cured 148 

Relieved 5 

Doubtful 9 

No  better 12 

No  recent  report  (11  of  these  may  be  considered  cer- 
tainly as  cured) 14 

Dead: 

As  result  of  operation 2 

Of  carcinoma  of  stomach 7 

Of  other  causes 8 

205 
90 


GASTROENTEROSTOMY  AND  AFTER. 

Group  4. — Hour-glass  Stomach. 

In  15  cases  gastro-enterostomy  was  performed,  being 
combined  in  6  with  other  operations — gastroplasty  or 
gastro-gastrostomy.  There  were  3  deaths.  In  one 
patient  regurgitant  vomiting  occurred  so  severely  as  to 
need  the  secondary  performance  of  entero-anastomosis. 
All  the  12  patients  are  now  perfectly  well,  and  in  the 
enjoyment  of  good  appetite  and  sound  digestion.  They 
are  all  cured  of  their  stomach  disorders. 

Such  is  the  detailed  analysis  of  the  cases  included  in 
each  separate  group.  In  order  that  an  accurate  general 
statement  as  to  the  effects  of  gastro-enterostomy  may  be 
made  the  cases  must  be  brought  together. 

A  summary  of  the  cases  gives  the  following  results: 

Group  1 8  patients  living;  8  patients  cured 

Group  2 23  patients  living;  19  patients  cured 

Group  3 188  patients  living;  159  patients  cured 

Group  4 12  patients  living;  12  patients  cured 

231  198 

The  present  condition  of  all  the  patients  is  as  follows : 

Patients  cured 198 

Improved 8 

No  better 12 

Doubtful 9 

Not  recently  reported 4 

231 

91 


GASTROENTEROSTOMY  AND  AFTER. 

Twenty-four  patients  are  dead — 9  as  a  result  of  the 
operation,  7  of  carcinoma  of  the  stomach,  8  from  other 
causes  unconnected  with  the  disease  of  the  stomach  or 
the  operation  performed  for  its  rehef. 

Conclusions. 

Such  is  a  brief  abstract  of  the  analysis  of  all  the  cases 
upon  which  I  operated  from  the  beginning  of  my  ex- 
perience to  the  end  of  the  year  1905.  The  result  of  the 
enquiry  into  the  after-history  enables  certain  conclu- 
sions to  be  drawn  which  may  guide  us  in  our  treat- 
ment of  the  chronic  disorders  of  the  stomach  in  the 
future.  I  would  submit  to  you  the  following  prop- 
ositions : 

1.  Gastro-enterostomy  is  a  short-circuiting  operation, 
and,  like  all  such  procedures,  acts  best  when  a  gross 
mechanical  obstruction  exists  in  the  normal  path  of  the 
intestinal  contents. 

2.  Experimental  work  shows  that  when  the  pylorus 
is  normal,  and  there  is  no  impediment  to  the  passage  of 
food  through  it,  the  opening  made  in  the  operation  of 
gastro-enterostomy  does  not  allow  of  the  escape  of  any 
of  the  gastric  contents  into  the  intestine. 

3.  The  operation,  therefore,  gives  the  best  results  in 
cases  where  there  is  organic  disease  in  the  prepyloric  or 
pyloric  region  of  the  stomach  or  duodenum,  or  when 

9S 


GASTROENTEROSTOMY  AND  AFTER. 

performed  on  the  cardiac  side  of  a  stenosis  in  the  body 
of  the  stomach. 

4.  When  an  ulcer  is  found  on  the  lesser  curvature 
towards  the  cardia,  it  should  be  excised  if  possible; 
gastro-enterostomy  is  not  necessary,  and  if  performed 
is  either  almost  useless  or  entirely  harmful. 

5.  When  there  is  a  suspicion  of  malignancy  in  an  ulcer 
or  ulcers  in  the  pyloric  region,  Rodman's  operation 
should  be  performed. 

6.  Under  no  circumstances,  and  in  compliance  with 
no  persuasion  however  insistent,  is  gastro-enterostomy 
to  be  done  in  the  absence  of  demonstrable  organic 
disease. 

7.  Regurgitant  vomiting,  formerly  the  most  trouble- 
some of  all  complications,  is  dependent  upon  faults  in 
the  operation  which  result  in  some  mechanical  ob- 
struction to  the  intestine.  These  faults  are  chiefly 
dependent  upon  the  presence  of  a  ''loop"  in  the  je- 
junum, but  may  also  be  caused  by  a  twist  in  the  in- 
testine around  its  longitudinal  axis  at  the  time  of  its 
application  to  the  stomach. 

8.  The  posterior  no-loop  operation,  with  the  vertical 
application  of  the  bowel  to  the  stomach,  is  the  best 
procedure. 


93 


GASTRO-ENTEROSTOMY  AND  AFTER. 


REFERENCES. 

1.  Annals  of  Surgery,  1906,  xliii,  539. 

2.  Arch.  f.  klin.  Chir.,  1900,  Ixx,  259. 

3.  Annals  of  Surgery,  1905,  xli,  686. 

4.  Bull.  et.  Mem.  de  la  Soc.  de  Chir.,  1907,  xxxiii,  1250. 

5.  La  Semaine  M^dicale,  1907,  ii,  513. 


The  Early  Diagnosis  and  Treatment 
of  Cancer  of  the  Stomach.* 

A  DEBATE  upon  the  early  diagnosis  and  the  treatment 
of  cancer  of  the  stomach  is  most  necessary,  for  the 
disease  claims  approximately  1500  victims  every  year 
in  England;  it  is  seldom  that  we  are  enabled  to  do  much 
to  relieve  those  who  suffer  from  it,  and  the  cases  that 
we  have  cured  are  so  few  as  to  be  almost  negligible. 
It  is  only  by  the  close  association  of  the  physician  and 
the  surgeon,  and  by  their  united  endeavours,  that  any 
hope  of  improvement  in  this  lamentable  state  of  affairs 
can  be  entertained.  The  opinions  which  I  am  about 
to  express  will  probably  not  meet  with  the  approval 
of  all,  may  perhaps  encounter  the  strong  opposition  of 
some,  but  they  are  views  which  I  have  been  brought  by 
degrees  to  hold  firmly,  and  I  am  here  to  speak  of  the 
faith  that  is  in  me. 

Anamnesis. 
It  has  long  been  a  practice  of  mine,  in  eliciting  the 
ananmesis  of  patients  referred  to  me  mth  any  abdomi- 
*  Reprinted  from  the  British  Medical  Journal,  April  3,  1909. 

95 


CANCER  OF  STOMACH. 


nal  disorder,  to  endeavour  to  disentangle  their  thoughts 
from  the  present  phase  of  the  disease,  in  order  to  con- 
centrate them  upon  the  very  earhest  departures  from 
health  of  which  they  have  knowledge.  A  little  per- 
suasion, a  little  patience,  and  constant  encouragement 
are  sometimes  necessary  before  the  whole  story  will 
be  told,  but  the  time  is  well  spent,  and  the  inaugural 
symptoms,  which  are  of  the  highest  significance,  are 
then  disclosed.  If  this  course  be  followed  with  pa- 
tients who  are  subsequently  shown,  by  operation,  or 
autopsy,  or  by  the  later  developments  of  their  dis- 
ease, to  be  suffering  from  carcinoma  of  the  stomach, 
all  three  different  types  of  clinical  history  will  be 
elicited. 

In  the  first  the  patient  stoutly  denies,  nor  can  any 
persuasion  induce  him  to  recall,  any  earlier  illness  or 
suffering  in  connexion  with  the  stomach.  He  will  say 
that  his  digestion  has  always  been  of  the  best,  and  that 
all  foods  have  been  alike  to  him,  all  have  been  taken 
with  zest,  and  that  "dyspepsia"  or  'indigestion"  has 
never  in  the  slightest  degree  troubled  him.  In  this 
condition  of  good,  even  robust,  health  there  has  been 
a  forcible  and  abrupt  intrusion  of  symptoms  hitherto 
unknown.  A  sudden  haemorrhage  from  the  stomach 
may  occur,  one  or  two  pints  of  blood  being  brought  up, 
and  from  that  moment  there  appear  the  symptoms  in- 

96 


CANXER  OF  ST0:MACH. 


dicative  of  a  gross  lesion  of  the  stomach.  The  ansemia 
which  follows  so  free  a  haemorrhage  persists  unduly,  and 
food,  especially  meats,  fat  or  lean,  becomes  distasteful. 
A  sense  of  uneasiness,  distress,  weakness  (it  is  variously 
described)  is  felt  in  the  epigastrium;  vomiting  may 
be  repeated,  weight  is  lost,  and  a  palpable  tumour 
rapidly  develops  in  the  stomach  wall.  As  a  character- 
istic example  of  this  class  I  \\dll  quote  the  following 
cases : 

Mr.  F.,  aged  thirty-four.  Sent  by  Dr.  Mitchell,  Oldham- 
Up  to  nine  weeks  before  I  saw  him,  on  October  26,  1908,  the 
patient  had  been  perfectly  well.  The  closest  examination  failed 
to  reveal  any  history  of  former  trouble  in  the  stomach.  His 
father-in-law  told  me  that  he  was  "the  heartiest  man  in  Old- 
ham." Nine  weeks  before  he  had  begun  to  suffer  discomfort 
one  hour  after  food;  there  was  a  feeling  of  fullness  and  flatulence 
in  the  epigastrium  and  abundant  eructation  of  gas,  which  at 
last  was  almost  rancid  in  its  offensiveness.  There  was  never 
severe  pain,  only  a  sense  of  "weight  and  stagnation."  The 
patient  repeatedly  said  he  felt  as  if  there  were  "something  in 
the  stomach  that  would  not  move  on";  and  he  felt  that  the  food 
could  not  get  awa3\  Four  weeks  later  he  began  to  vomit,  and 
did  so  every  day  for  more  than  a  week;  then  occasionally  there 
was  a  day  when  he  did  not  vomit,  and  when  that  was  so  he  after- 
wards noticed  food  which  had  been  taken  the  pre\dous  day  in 
the  vomited  material.  Vomiting  had  ceased  for  over  a  week 
before  I  saw  him.  There  had  never  been  haematemesis  nor 
melaena.  From  the  beginning,  but  especially  during  the  last 
month,  he  had  got  weaker  and  thinner  and  very  much  paler. 
When  I  saw  him  he  was  profoundly  anaemic;  his  face  was  of  a 
white,  waxen  appearance,  and  the  mucous  surfaces  were  ahnost 
bloodless.  In  the  epigastrium  I  found  a  tumour  whose  upper 
7  97 


CANCER  OF  STOMACH. 


margin  was  well  defined,  but  whose  lower  was  indefinite.  The 
tumour  moved  on  respiration;  there  was  no  dilatation  of  the 
stomach.  The  contents  showed  no  free  HCl;  lactic  acid  was 
present.  Oppler-Boas  bacilli  were  innumerable.  I  found  on 
opening  the  abdomen  there  was  a  growth  along  the  whole  length 
of  the  lesser  curvature,  and  that  throughout  the  stomach  there 
were  deposits  of  growth  resembfing  boiled  sago  grains.  Glands 
in  all  directions  were  enlarged,  and  there  was  a  very  large  second- 
ary growth  in  the  liver.  He  died  on  December  23,  1908.  The 
growth  in  the  fiver  had  increased  considerably. 

Mr.  J.,  aged  sixty-three.  Sent  by  Dr.  Mafim,  Rochdale. 
Up  to  August,  1907,  he  was  perfectly  well.  He  was  a  man  who 
had  led  a  busy  life,  amassed  a  fair  fortune,  and  had  lived  care- 
fully. There  had  never  been  any  indigestion  nor  any  abdominal 
disorder  of  any  kind.  There  was,  in  fact,  as  the  patient  said, 
"a  clean  bill  of  health."  In  August,  1907,  he  had  a  severe 
attack  of  hsematemesis;  he  did  not  remember  ever  having 
vomited  before,  and  he  had  never  vomited  since.  After  this 
he  was  weak  and  ill  and  very  anaemic,  but  he  gradually  improved 
in  appearance  and  returned  to  business.  He  had,  however, 
lost  all  appetite;  he  could  not  take  any  meat,  and  soon  gave  up 
all  sofids.  Weight  was  lost  rapidly.  I  saw  him  on  March  14, 
1908.  He  had  the  frame  of  a  big  man,  but  his  clothes  hung 
loosely  upon  him.  He  was  very  anaemic,  and  capillary  vessels 
stood  out  prominently  against  the  white  background  of  his 
cheeks.  He  took  very  small  quantities  of  soups  and  milk  and 
tea.  In  the  epigastrium  a  large,  ill-defined  tumour  could  be 
felt.  Lavage  and  examination  by  test-meal  showed  long  stag- 
nation of  all  the  contents  of  the  stomach,  which  contained  blood, 
yeast,  pus,  and  bacteria.  At  the  operation  I  found  a  growth 
involving  the  lesser  curvature  near  the  pylorus,  and,  passing 
behind  the  stomach,  adhering  to  the  pancreas,  it  involved  the 
greater  curvature  also.  There  were  several  sago-fike  bodies 
on  the  surface  of  the  pyloric  portion  of  the  stomach.  I  per- 
formed anterior  gastro-enterostomy,  with  sHght  temporary 
benefit. 


CANCER  OF  STOMACH. 


In  the  second  class  are  placed  all  those  cases  in  which 
a  clear  history  of  chronic  gastric  ulcer  can  be  obtained. 
In  some  of  these  cases  there  has  been  only  one  attack, 
or  possibly  two  or  three  attacks  rapidly  succeeding  one 
another  within  the  period  of  a  single  illness,  followed  by 
a  complete  abeyance,  or  at  least  a  complete  latency  of 
all  symptoms  until  the  onset  of  the  malignant  disease. 
In  other  cases  the  patients  have  had  a  long  series  of 
attacks,  in  many  respects  closely  similar  to  the  present 
one,  of  ''indigestion."  These  attacks  have  been  char- 
acterised by  pain,  appearing  always  at  a  definite 
interval  after  food,  the  interval  being  longer  or  shorter 
according  to  the  character  of  the  food  taken.  After  a 
solid  meal  the  pain  appears  rather  more  slowly,  but  is 
unmistakably  more  severe;  after  a  meal  consisting  of 
fluids  only  the  pain  comes  more  quickly,  is  less  severe, 
and  passes  away  more  rapidly.  The  pain  varies  in  its 
position,  but  is  usually  referred  to  the  middle  line, 
where  a  tender  spot  can  generally  be  discovered.  The 
left  or  the  right  costal  margin  may  be  tender,  and  the 
radiations  of  the  pain  may  be  to  one  side  or  another, 
or  through  to  the  back.  Vomiting  is  not  a  frequent 
symptom;  when  it  occurs,  it  brings  instant  relief,  and 
a  habit  of  inducing  it  may  accordingly  be  developed 
by  the  patient,  who  is  confident  of  obtaining  ease  in 
that  way.     Attacks  are  prone  to  come  more  often  in 

99 


CANCER  OF  STOMACH. 


cold  weather,  or  as  a  result  of  a  chill,  or  by  reason  of 
increased  work,  worry,  and  anxiety.  In  some  cases 
the  evidences  of  stasis  may  develop,  though  they  rarely 
become  dominant.  The  patient,  long  accustomed  to 
suffering,  may  be  resigned  to  the  restricted  diet  of  a 
'^  chronic  dyspeptic."  One  patient — a  lady  who  cele- 
brated her  silver  wedding  a  few  days  after  I  had 
operated  upon  her — had  never,  within  the  period  of 
her  husband's  knowledge  of  her,  eaten  one  solid  meal. 
The  foods  usually  taken  are  of  the  light,  easily  masti- 
cated, and  easily  propelled  foods.  In  the  history  of 
many  patients,  however,  there  are  ''latent  periods" 
during  which  food  can  be  taken,  if  not  with  a  keen 
relish,  at  least  with  better  appetite  and  enjoyment 
than  is  usual.  But  after  such  a  period  there  is  again 
the  breakdown,  and  pain  in  its  characteristic  form 
returns.  An  occasional  indiscretion,  even  when  the 
patient  is  quite  well,  may  bring  a  reminder  of  the  need 
for  care,  and  certain  articles  of  diet  must  be  sedulously 
avoided  at  all  times.  Experience  of  repeated  troubles 
has  imposed  upon  the  patient  the  necessity  for  care 
in  the  selection  of  a  dietary.  The  ''attacks"  are 
without  question  due  to  a  chronic  gastric  ulcer.  When 
we  operate  to-day  upon  patients  who  recount  these 
symptoms,  the  chronic  ulcer  can  always  be  found  and 
demonstrated.     After  a  history  of  repeated  attacks, 

100 


CANCER  OF  STOMACH. 


alike  in  onset,  in  character,  duration,  and  relief,  comes 
one  attack  at  first  so  closely  resembling  all  the  others 
that  it  is  with  difficulty  to  be  distinguished  as  having  a 
special  significance,  but  by  degrees  revealing  a  sinister 
importance  and  leading  on  by  stages,  presently  to  be 
described,  to  a  condition  clearly  due  to  cancer.  This 
group  is  indubitably  the  most  common.  Approxi- 
mately, two  out  of  every  three  cases  in  which  carcinoma 
of  the  stomach  is  found  in  my  series  give  a  history  of 
this  kind.     One  or  two  examples  may  be  given: 

Mr.  M.,  aged  forty-eight,  sent  by  Dr.  Wesley  Smith,  seen 
by  me  August  8,  1908.  The  patient  has  been  "bothered  with 
indigestion  for  years."  The  pain  has  alwaj'-s  been  definitely 
related  to  the  taking  of  food.  His  meals  have  often  been  hasty; 
he  has  "bolted"  solid  food,  and  the  meal  times  have  been  most 
irregular.  After  special  stress  of  work,  he  has  often  had  to 
"give  up  entirely"  because  of  an  attack  of  indigestion.  Pain 
has  come  usually  one  and  one-half  hours  after  food,  and  the  food 
has  then  begun  to  regurgitate;  and  a  feeling  of  great  oppression 
and  fullness  has  been  reheved  bj*  belching.  About  an  hour 
after  food  he  had  "miserable  discomfort,"  which  a  hot  drink 
would  often  reheve.  The  present  attack  began  about  Christ- 
mas, 1907,  and  has  continued  ever  since.  He  has  lost  over  4  st. 
in  weight.  Recently  his  discomfort  has  only  been  reheved  by 
getting  the  food  back.  He  is  easy  when  the  stomach  is  empty, 
and  never  at  any  other  time.  On  examination,  a  tumour  is 
palpable,  and  on  shght  inflation  peristaltic  waves  are  \'isibie. 
Operation  October  14,  1908.  A  large  tumour  occupying  the 
lesser  curvature  up  to  the  pylorus,  and  extending  down  both 
surfaces.  Partial  gastrectomy.  The  growth  was  malignant, 
and  had  begun  in  a  saddle-shaped  ulcer. 

Mrs.  A.,  aged  forty-five,  sent  by  Dr.  Horsfall,  Slaithwaite, 

101 


CANCER  OF  STOMACH. 


seen  July  10,  1907.  The  patient  says  that  she  has  suffered  from 
her  stomach  "all  her  life."  When  asked  to  be  more  precise, 
she  says  that  she  remembers  very  well  an  attack  when  she  was 
twenty  years  old,  and  that  was  not  the  first.  In  an  attack  pain 
came  about  one  hour  after  food ;  the  pain  was  worse  after  heavy 
foods,  but  came  more  quickly  after  liquids.  Vomiting  at  first 
did  not  occur,  has  since  been  frequent,  but  has  always  brought 
relief.  No  blood  has  been  seen  at  any  time.  In  the  intervals 
between  attacks  she  feels  very  well;  the  longest  interval  was 
rather  more  than  a  year  in  duration.  The  last  attack  began  at 
Christmas,  1906.  The  pain  was  of  the  same  character,  but 
became  by  degrees  more  severe.  Diet  was  restricted  to  fluids, 
but  pain  persisted,  and  recently  has  been  almost  constant. 
Vomiting  has  been  frequent  during  the  last  few  weeks.  Has 
lost  in  this  attack  20  lb.  Does  not  improve  with  the  same 
treatment  as  before.  I  operated  upon  her  on  July  19,  1907, 
and  performed  partial  gastrectomy.  There  was  a  large  pre- 
pyloric growth;  a  great  many  glands  in  both  omenta,  and  the 
right  suprapancreatic  glands  and  the  subpyloric  group  were 
especially  large.  The  patient  died  in  September,  1908,  having 
had  three  "fits"  on  the  two  days  preceding  her  death. 

In  3  cases  in  my  series  perforation  of  an  ulcer  had 
occurred  twenty-six,  ten,  and  four  years  previously.  In 
the  first  case  the  perforation  had  been  of  the  ''chronic" 
type,  and  a  perigastric  abscess  had  formed.  In 
the  others  the  history  suggested  that  the  perforation 
had  been  of  the  "subacute"  type,  and  the  conditions 
found  at  the  operation  lent  strong  support  to  this  view. 

Symptoms  of  Cancer. 
This  being  the  early  history,  what  are  the  symptoms 
which  are  present  in  the  final  attack  which  proves  to 

102 


CANCER  OF  STOMACH. 


be  due  to  malignant  disease?     The  patient  notices,  by 
almost  imperceptible  degrees,  that  the  relief  which  has 
formerly  come  for  a  brief  period  after  a  meal  is  cur- 
tailed, that  pain  comes  more  speedily  or  is  not  reheved 
at  all.     It  is  not  long,  therefore,  before  food  is  taken  in 
lesser  quantity,  and  becomes  restricted  to  fluid  forms 
alone.     There  is  often  a  distaste  for  meat,  especially 
for  fat  meats,  as  observers  long  ago  noticed.     The  zest 
for  food  is  lost  entirely,  and  there  is  often  a  positive 
repugnance  to  it.     While  the  ulcer  is  still  simple,  there 
is  rarely  a  distaste  for  food;   on  the  contrary,  there  is 
often  a  feeling  of  great  desire  for  food,  but  experience 
has  shown  that  indulgence  is  followed  by  distress  or 
pain.     I  have  commonly  heard  it  said,  ''I  could  eat 
anything,  but  I  dare  not."       In  patients  suffering  from 
well-estabhshed  cancer  this  is  never  heard;   the  cry  is 
always  that  the  thought  of  food  is  abhorrent,  and  it  is 
difficult  to  persuade  a  patient  to  overcome  his  intoler- 
ance.    There  is,  then,  little  or  no  freedom  from  pain, 
and  a  sense  of  uneasiness,  or  '' sinking"  in  the  epigas- 
trium;   yet  the  pain  is  never  severe,  is  often  not  a 
matter  of  complaint  at  all.     Food  which  has  been  taken 
"lies  heavily"  on  the  stomach,  and  regurgitation  of  it 
may  occur,  and  a  nauseous,  bitter,  but  not  acid,  taste 
is  noticed.     An  early  sjinptom  I  have  often  observed 
is  the  copious  discharge  of  an  acid  or  bitter  fluid  from 

103 


CANCER  OF  STOMACH. 


the  stomach  into  the  mouth.  There  is  often  much 
flatulence  and  eructation  of  gas.  There  are  times 
when  the  gas  and  the  vomited  matters  are  unen- 
durably  offensive.  The  lessening  of  the  size  of  the 
stomach  by  the  discharge  of  either  gaseous  or  fluid 
contents  always  brings  relief.  Very  early  in  the 
attack  anaemia  is  seen;  it  is  not,  as  it  may  have 
been  before,  the  anaemia  which  can  be  attributed 
to  a  large  and  noticeable  loss  of  blood;  it  is  rather 
a  gradually  deepening  pallor,  the  face  seeming  of  a 
whiter  colour  than  the  rest  of  the  body.  It  is  not 
infrequent  for  the  colour  to  be  of  the  faintest  yellow 
tinge,  and  the  resemblance  to  the  hue  of  pernicious 
anaemia  is  very  close.  In  all  such  cases  there  is  a 
continuing  loss  of  blood,  as  examination  of  the  stomach- 
contents  removed  by  the  tube,  or  of  the  faeces,  will 
show.  Anaemia  is,  perhaps,  the  most  striking  of  all 
the  signs  which  indicate  the  onset  of  carcinoma  in  the 
stomach.  The  appearance  of  the  patient  with  pallid, 
shrunken  face,  and  features  preternaturally  sharp,  the 
skin  being  dry  and  harsh  and  withered,  will  often  rouse 
the  first  suspicion  of  the  gravity  of  his  disease.  Loss 
of  weight  is  continuous;  at  first  it,  perhaps,  hardly 
attracts  attention,  but  as  soon  as  note  is  taken  of  it, 
a  steady  and  unchecked  wasting  is  observed.  General 
weakness,  indifference  to  many  of  the  affairs  of  life 

104 


CANCER  OF  STOMACH. 


which  formerly  held  an  absorbing  interest,  languor  and 
lassitude  are  all  seen  in  greater,  than  in  less,  degree. 
Such  is  the  complete  picture  seen  in  the  majority  of 
the  cases  of  carcinoma.     A  discrimination  of  two  dis- 
tinct types  can  usually  be  found  in  all  cases  where  the 
pyloric  half  of  the  stomach  is  the  seat  of  disease.     These 
I  would  designate  as  cases  of  ''pyloric"  and  of  ''prepy- 
loric" growth.     In  the  former  the  symptoms  almost 
from  the  first  suggest  the  presence  of  a  hindrance  at 
or  near  the  pylorus.     Vomiting  is  among  the  very  early 
symptoms,  and  dilatation  of  the  stomach,  with  stagna- 
tion, and  the  periodic  return  of  the  long-delayed  food, 
occur.     These    cases    are  recognised  early,  owing  to 
the  inability  of  the  patient  to  take  food,  either  soHd  or 
liquid,  with  comfort,  and  to  the  overt  character  of  the 
cardinal  symptom — vomiting.     The  danger  is  in  mis- 
taking, as  I  have  unhappily  done,  on  more  occasions 
than  one,  the  growth  for  a  chronic  ulcer.     A  palliative 
operation,  gastro-enterostomy,  is  then  performed,  when 
a  radical  operation,   partial  gastrectomy,  is  needed. 
In  the  "prepyloric"  form  the  symptoms  are  such  as  I 
have  already  described;  they  are  general  and  constitu- 
tional rather  than  local,  and  are,  therefore,  less  com- 
pelling in  their  interest.     The  ulcer,  and  the  growth 
which  follows  it,  are  found  upon  the  lesser  curvature 
away  from  the  pylorus;   the  ulcer  has  probably  been, 

105 


CANCER  OF  STOMACH. 


and  may  often  be  shown  to  be,  saddle-shaped,  and  con- 
sequently a  high  degree  of  obstruction  does  not  come 
till  late.  The  mere  presence  of  a  growth  on  the  lesser 
curvature — or,  indeed,  of  an  ulcer  also — seems  to  do 
something  to  impede  the  passage  of  food  onwards, 
possibly  by  entanglement  of  the  nerve-supply;  a  zone 
of  muscle  of  lessened  power  offers  obstruction  in  some 
sort,  and  causes  both  stasis  and  vomiting. 

In  the  third  group  the  patients,  who  are  generally 

between  forty  and  forty-five  years  of  age,  give  a  history 

which,  in  all  its  essential  details,  is  identical  with  that 

in  Group  2.     But  there  is  one  significant  omission. 

No  history  of  any  illness  which  can  be  referred  to  a 

structural  lesion  in  the  stomach  can  be  elicited.     The 

whole  clinical  course  is  comprised  in  the  one  sustained 

illness  which,  without  haste  but  without  pause,  has 

brought  the  patient  into  a  condition  of  serious  ill-health. 

The  symptoms  in  their  earlier  stages  are  pain,  which 

appears  sooner  or  later  after  food,  and  is  worse  after 

solid  food  to  such  a  degree  that  liquids  soon  form 

the  whole  dietary;  occasional  vomiting,  and  possibly 

hsematemesis  or  rarely  melsena,  and  loss  of  weight. 

There  is  nothing  alarming  or  particularly  distressing 

in  the  symptoms,  but  it  is  their  persistence  rather  than 

their    prominence    which    finally    attracts    attention. 

Wasting  anaemia  and  perhaps  vomiting  become  con- 

106 


CANCER  OF  STOMACH. 


spicuous,  and  at  last  it  is  realised  that  the  patient  is 
probably  attacked  by  some  serious  organic  disease. 

At  the  operation  carcinoma  is  found,  and,  most  im- 
portant point  of  all,  the  growth,  in  my  experience,  is 
sometimes  found  to  be  in  the  site  of  a  chronic  ulcer. 
In  this  group  of  cases  there  is  no  suspicion,  clinically, 
or  only  a  very  vague  suspicion,  that  a  chronic  ulcer  of 
the  stomach  has  ever  been  present.  It  is  the  patho- 
logical disclosures  which  make  it  probable  or  certain 
that  in  many  an  ulcer  has  formed,  an  ulcer  which  at 
the  moment  of  its  full  development  has  straightway 
become  invaded  by  an  insidious  malignant  process. 
The  change  which  occurs  in  this  ulcer  is  in  every  feature 
the  same  as  that  which  is  noticed  in  the  cases  in  Group 
2;  but  in  these  the  change  comes  in  the  first  life  of  the 
ulcer,  in  the  others  only  after  it  has  many  times  healed 
and  as  often  broken  down  again.  The  following  is  a 
good  example: 

Mrs.  B.,  aged  forty-six.  Sent  by  Dr.  McLeod,  Outwood. 
Seen  by  me  October  10,  1908.  The  patient  had  been  perfectly 
well  up  to  six  months  before.  She  then  began  to  suffer  pain  one 
to  one  and  a  half  hours  after  food;  vomiting  occurred  shortly 
afterwards,  and  always  gave  some  rehef.  There  was  never 
hajmatemesis.  The  pain  gradually  increased  in  severity,  and 
latterly  had  been  much  worse  after  sohd  food,  especially  meat. 
At  first  there  were  periods  during  which  she  felt  quite  well, 
but  lately  the  suffering  has  been  continuous,  and  weight  has 
gradually  been  lost  to  the  extent  of  11  lb.     On  examination  there 

107 


CANCER  OF  STOMACH. 


was  a  dilated,  visibly  acting  stomach,  and  a  lump  the  size  of  a 
hen's  egg  was  palpable  at  the  pyloric  end  of  the  stomach. 

Operation. — The  palpable  tumour  was  seen  to  be  a  mass  of 
malignant  glands  ("subpyloric"  group).  On  the  anterior  sur- 
face of  the  stomach,  close  to  the  pylorus,  was  a  hard  round  scar, 
with  radiating  puckers  from  it.  Partial  gastrectomy.  Recovery. 
An  examination  of  the  specimen  showed  a  large  chronic  ulcer  of 
the  stomach,  at  the  lower  part  of  which  the  edge  was  raised  into 
a  mass  the  size  of  a  Barcelona  nut.  This  was  mahgnant,  as  also 
were  the  glands  underlying  it. 

Relation  of  Gastric  Ulcer  to  Cancer. 
In  the  remarks  I  have  already  made  I  have  done 
something  more  than  hint  at  the  connexion  between 
ulcer  of  the  stomach  and  cancer.  Are  we  entitled  to 
saj^  that  there  is  any  proved  connexion  between  the 
two?  If  we  are,  then  chronic  ulcer  of  the  stomach 
must  be  ranked  among  the  "precancerous"  conditions; 
and  if,  further,  the  connexion  be  proved  to  be  of  either 
moderate  or  large  frequency,  cancer  of  the  stomach  is 
surely  robbed  of  some  of  its  terrors,  for  it  is  doubtless 
then  to  be  enrolled  among  the  preventable  diseases. 
What  is  the  evidence?  In  a  previous  paper,  read  before 
the  Clinical  Society  of  London  in  February,  1906,  I 
collected  and  analysed  all  the  cases  of  cancer  of  the 
stomach  (58  in  number)  upon  which  I  had  operated  up 
to  July,  1905.^  In  the  last  22  cases  a  history  of  chronic 
gastric  ulcer  was  clearly  obtained  in  16;  in  one  case 
there  had  been  a  subacute  perforation  of  an  ulcer  on 

108 


CANCER  OF  STOMACH. 


the  lesser  curvature  near  the  pylorus.  In  one  case  the 
"attack"  of  gastric  ulcer  had  occurred  twenty-six 
years  before;  in  the  interval  the  health  had  been  good 
and  digestion  sound,  though  care  had  always  been 
exercised  in  the  matter  of  diet. 

Almost  identically  the  same  proportion  has  held  good 
for  my  later  cases,  numbering  over  100,  and  I  am  there- 
fore in  a  position  to  say  that  of  all  patients  operated 
upon  by  me  for  cancer  of  the  stomach,  approximately 
two  in  every  three  have  had  a  history  of  previous 
gastric  ulcer.  In  the  majority  of  those  who  give  this 
history  there  has  been  a  constant  succession  of  attacks, 
similar  in  all  their  chief  manifestations  and  brought 
about  by  similar  causes.  In  the  last  attack  the  symp- 
toms have  been  of  a  graver  nature,  more  protracted, 
not  amenable  to  the  treatment,  nor  relieved  by  the 
drugs  which  proved  successful  before;  and  by  degrees 
it  has  become  unmistakable  that  this  attack  is  likely 
to  prove  of  a  far  more  serious  character. 

From  the  clinical  point  of  view  it  is,  therefore,  cer- 
tain that  we  must  look  for  the  inaugural  symptoms  of 
cancer  of  the  stomach  rarely  among  those  whose  former 
health  has  been  good,  often  among  those  whose  anamne- 
sis tells  sometimes  of  one,  but,  as  a  rule,  of  many  at- 
tacks of  ''dyspepsia"  or  ''indigestion,"  as  they  may  be 
called.     These  attacks  of  pain  come  after  food,  are 

109 


CANCER  OF  STOMACH. 


definitely  related  to  the  taking  of  food,  are  eased  for  a 
time  by  food,  and  there  are  also  vomiting,  inability 
to  take  or  temporary  dislike  for  solids,  and  loss  of 
weight;  the  attacks,  that  is  to  say,  are  clearly  to  be 
referred  to  the  presence  of  a  chronic  gastric  ulcer.  If, 
therefore,  we  are  to  concentrate  our  attention  upon  the 
early  symptoms  of  cancer  of  the  stomach,  it  is  the 
patient  whose  stomach  has  long  been  a  source  of  trouble 
to  him  that  must  chiefly  engage  our  attention.  But  it 
is  necessary  to  say  that  this  patient,  who  is,  so  to  speak, 
the  most  promising  candidate  for  carcinoma  of  the 
stomach,  can  be  prevented  from  developing  this  hor- 
rible affliction  by  a  timely  attention  to  the  earlier 
simple  disease.  Cancer  of  the  stomach,  if  it  follows  in 
the  majority  of  cases  upon  chronic  ulcer  of  the  stomach, 
is  so  far,  and  in  such  numbers,  a  preventable  disorder. 
In  the  surgical  treatment  of  chronic  gastric  ulcer  by  the 
performance  of  gastro-enterostomy,  or  of  Rodman's 
operation,  may  be  the  means  of  destroying  the  chances 
of  a  late  malignant  change  from  an  early  simple  con- 
dition. It  has  often  been  said  that  ''the  onset  and 
persistence  of  dyspepsia  in  a  man  over  forty  years  of 
age,  who  had  previously  enjoyed  good  health,  is  a 
suspicious  circumstance,"  pointing  probably  to  the 
onset  of  carcinoma.  I  have  found  that  in  such  cases 
the  disease  is  more  often  simple  than  malignant,  and 

110 


CANCER  OF  STOMACH. 


that  the  lesion  found  is  more  frequently  duodenal  than 
gastric. 

I  am  only  too  well  aware  of  the  doubt,  even  perhaps 
of  the  hostility,  with  which  the  suggestion  has  been 
received  that  ulcer  of  the  stomach  and  cancer  stand 
often  in  the  relationship  I  have  indicated.  But  im- 
partial inquiry  into  the  history  of  a  long  series  of  cases 
Tvall  support,  I  know  well,  the  views  I  have  expressed. 
Clinically,  there  can  be  no  longer  any  substantial  doubt 
of  the  connexion.  Is  there  any  valid  pathological 
evidence  to  support  the  belief  which  clinical  experience 
has  stimulated?  I  have  no  hesitation  in  saying  that 
the  pathological  evidence  now  available  supports  fully 
the  contention  I  have  stated.  In  what  manner  should 
we  expect  that  evidence  to  be  obtained?  I  venture  to 
answer  that  it  could  only  be  obtained  from  specimens 
examined  in  an  early  stage  of  the  disease,  at  a  time 
when  the  primary  simple  disease  and  the  later  cancerous 
change  can  be  seen  together.  It  is,  then,  necessary 
also  to  show  that  the  former  condition  is  earlier  than 
the  latter.  A  moment's  thought  will  convince  one  of 
the  truth  that  a  specimen  of  this  kind  is  hardly  to  be 
found  upon  the  post-mortem  table  in  the  body  of  one 
who  has  succumbed  at  last  to  the  steady  and  unchecked 
extension  of  a  malignant  growth.  The  only  specimens 
which  are  likely  to  furnish  valid  evidence  must  be 

111 


CANCER  OF  STOMACH. 


obtained  by  operation.  The  best  of  these  specimens 
are  found  when  a  chronic  ulcer,  as  the  appearance 
suggests,  is  removed  by  Rodman's  operation.  Though 
no  suspicion  of  mahgnancy  may  have  crossed  the 
surgeon's  mind,  the  pathological  examination  will  dis- 
close the  undoubted  evidence  of  early  malignant  dis- 
ease in  an  area  where  the  ancient  marks  of  simple 
disease  are  plainly  to  be  seen.  In  this  connexion  one 
cannot  but  offer  a  tribute  to  the  remarkable  work  which 
has  been  done  in  the  clinic  of  Dr.  W.  J.  Mayo  and  Dr. 
C.  H.  Mayo  at  Rochester.  I  had  the  privilege  a  few 
months  ago  of  seeing  the  specimens  of  partial  gastrec- 
tomy removed  by  them,  and  of  having  the  pathological 
conditions  demonstrated  to  me.  No  one  who  has  seen 
the  evidence  there  produced  doubts  any  more  that 
cancer  of  the  stomach  is  frequently  the  offspring  of 
an  early  simple  disease.  Dr.  W.  J.  Mayo^  has  re- 
corded the  fact  that,  in  180  cases  of  resection  of  the 
stomach,  cancer  was  demonstrated  to  have  sprung  up 
in  the  base  of  an  ulcer  in  97;  that  is,  in  54  per  cent. 
My  own  experience  supports  this  statement  fully; 
indeed,  I  have  myself  found  the  percentage  even  a  little 
higher  in  my  recent  cases. 

The  connexion  between  chronic  ulcer  of  the  stomach 
and  carcinoma  I  hold,  therefore,  to  be  established  so  far 
as  Group  2  is  concerned.     Is  there  any  relationship 


CANCER  OF  STOMACH. 


between  the  acute  cases  of  cancer  of  the  stomach,  cases 
which  seem  to  have  in  them  something  akin  to  an  acute 
infection,  and  ulcer?  There  is  no  history  of  chronic 
ulcer  in  this  class  of  case;  the  disease  seems  to  begin 
acutely  and  to  spread  rapidly;  in  my  own  work  no 
permanent  relief  has  ever  followed  operative  treatment, 
and  the  benefit  obtained  by  the  palliative  operation  of 
gastro-enterostomy  is  too  often  quite  inconsiderable. 
Recently  I  have  come  to  believe  it  possible  that  in  these 
cases  also  an  ulcer  may  be  the  starting-point  of  the 
malignant  process.  The  ulcer  in  such  cases  is  of  the 
'^ acute"  type;  one  or  more  '^hsemorrhagic  erosions" 
are  present,  and  in  these  cancer  is  deposited  and 
spreads  there  with  the  most  intense  rapidity. 

If  carcinoma  should  be  conclusively  proved  to  be  the 
final  change  in  the  long  series  of  changes  which  have 
led  up  to  and  established  a  chronic  ulcer  in  the  stomach, 
is  it  not  in  this  case  merely  repeating  the  experience 
we  have  gained  of  its  habits  in  other  parts  of  the  body? 
We  know  how  frequently  cancer  of  the  tongue  develops 
as  a  last  change  in  a  series  of  conditions  all  of  which  are 
simple.  It  is  only  the  bare  truth  to  say  that  cancer 
almost  never  develops  in  a  tongue  previously  healthy; 
where  a  malignant  ulcer  is  present,  other  changes  are 
seen  around  it,  and  these  have  been  present,  always 
for  months,  often  for  years.  Cancer  is  there  only  a 
8  113 


CANCER  OF  STOMACH. 


local  exaggeration  of  or  a  later  change  in  a  condition  of 
things  distributed  over  other  parts,  or  over  the  whole 
of  the  tongue.  It  is  the  same  with  the  lip,  and  with 
the  ulceration  of  old  scars  due  to  burns.  The  develop- 
ment of  eancer  on  the  corona  as  a  result  of  the  irrita- 
tion of  smegma  retained  by  a  too  long  and  too  tight 
prepuce  was  pointed  out  more  than  a  century  ago  by  the 
first  William  Hey,  of  Leeds.  In  the  breast  the  trans- 
formation from  chronic  mastitis  to  malignancy  is  no 
longer  doubted.  In  the  gall-bladder  it  is  commonly 
seen.  And  instances  might  easily  be  multipHed.  Surely 
the  one  thing  of  which  surgeons  feel  sure  in  respect 
of  cancer  is  that  it  seems  most  often  to  occur  in  those 
parts  where  mild  irritation  has  long  been  present. 

Exploratory  Incision. 
A  review  of  the  cases  which  have  been  under  my 
own  care  has  convinced  me  that  though  the  history, 
especially  in  so  far  as  it  tells  of  former  attacks  of 
chronic  gastric  ulcer,  may  awaken  a  keen  suspicion  as 
to  the  presence  of  a  carcinoma  in  the  stomach,  and 
though  all  the  contributory  evidence  to  be  derived 
from  the  chemical  examination  of  the  stomach  contents 
may  go  towards  a  confirmation  of  the  diagnosis,  there 
is  only  one  means  of  making  an  assured  diagnosis  in 
an  early  stage.     An  inspection  of  the  parts,  and  this 

114 


CANCER  OF  STOMACH. 


alone,  and  that  indeed  not  always,  can  give  us  the  in- 
formation upon  which  a  probable  diagnosis  can  be 
made.  It  is  necessary  for  us  to  realise  that  by  any 
other  methods  than  this  one  a  positive  diagnosis  of 
cancer  in  the  stage  when  it  is  capable  of  successful 
treatment  is  almost  impossible.  If  the  patients  who 
are  suffering  from  this  most  insidious  and  most  terrible 
disease  are  to  have  any  fuller  prospect  of  relief,  or  of 
cure,  the  use  of  the  exploratory  operation  must  be 
greatly  increased.  I  deprecate  more  strongly,  I  be- 
lieve, than  most  surgeons  the  adoption  of  the  ''explora- 
tory incision";  but  every  argument  and  all  experience 
show  that  in  cases  of  carcinoma  of  the  stomach  no  other 
method  than  this  offers  any  slenderest  hope  for  the 
betterment  of  the  present  deplorable  condition  of 
affairs.  But  before  we  are  entitled  to  advise  any 
patient  to  undergo  this  operation  we  must  be  confident 
that  there  is  a  well-grounded  suspicion  that  some  con- 
dition not  admitting  of  remedy  by  any  other  than 
surgical  means  will  be  found. 

Indications  for  Operation. 

I  think  that  an  operation  should  be  advised  in  the 
following  circumstances : 

(a)  In  all  cases  of  chronic  gastric  ulcer.  The  recent 
experience  of  surgeons  has  shoTsu  that  a  diagnosis  of 

115 


CANCER  OF  STOMACH. 


chronic  gastric  ulcer  can  be  made  with  great  accuracy, 
and  that  not  only  the  presence,  but  also  the  position,  of 
the  ulcer  can  be  accurately  predicted.  When  repeated 
''attacks"  occur,  it  is  idle  to  consider  any  other  than 
operative  treatment,  for  nothing  else  can  give  perma- 
nent relief.  In  any  attack  occurring  in  a  patient  over 
forty  years  of  age  the  need  for  surgical  intervention  is 
becoming  urgent. 

(h)  When  gastric  stasis  is  present.  This  is  a  condi- 
tion the  existence  of  which  is  easily  determined.  If 
there  are  symptoms  suggesting  structural  disease  in  a 
stomach  incapable  of  emptying  itself  completely  in 
from  ten  to  twelve  hours,  then  the  conditions  which 
exist  are  mechanical,  and  can  be  remedied  by  none 
other  than  mechanical  means. 

(c)  When  a  tumour  is  present.  The  tumour  may  be 
simple  or  malignant,  but  research  is  better  conducted 
by  inspection  than  by  any  other  means  at  our  disposal. 

In  these  three  conditions  medical  treatment  may  do 
something  to  relieve:  it  can  do  nothing  to  cure.  There 
is  accordingly  no  reason  for  delay  in  advocating  opera- 
tion. If  this  is  done,  and  done  early,  many  cases  of 
carcinoma  that  now  drift  quietly  into  the  inoperable 
stage  may  be  saved. 

The  position  seems  now  to  be  this — that  there  are 
no  signs  or  symptoms  clearly  indicative  of  the  presence 

116 


CANCER  OF  STOMACH. 


of  gastric  cancer;  there  is  no  refinement  of  clinical 
inquiry  nor  any  endowment  of  clinical  acumen  which 
will  enable  a  confident  diagnosis  to  be  made  in  an  early 
stage;  inspection  of  the  stomach  during  an  operation 
carried  out  when  definite  faults  in  its  w^orking  are  known 
will  permit  of  the  early  discovery,  or  of  the  prevention 
of  a  certain  proportion  of  the  cases  of  cancer.  The 
surgeon  must  not  ask  the  physician  for  a  sign  which 
will  reveal  the  presence  of  this  disease  to  him,  but  he  • 
can  and  should  require  that  those  conditions  which  are 
only  to  be  remedied  by  operative  measures  should  be 
referred  to  him  not  in  their  advanced  or  terminal  stages, 
but  at  the  earliest  moment  of  their  recognition.  The 
success  which  has  followed  the  surgical  treatment  of 
gastric  disorders  justifies  this  simple  request. 

Chemical  Analysis  of  Gastric  Contents. 
A  point  which  cannot  be  ignored  in  any  discussion 
upon  the  early  recognition  of  cancer  of  the  stomach  has 
reference  to  the  condition  of  the  stomach  contents. 
Much  has  been  written  with  regard  to  the  value  of  a 
chemical  examination  of  the  stomach  contents  in  cases 
of  gastric  carcinoma.  It  is  my  practice  to  have  all 
stomach  cases  examined  as  a  matter  of  routine,  and  I 
place  some  reliance  upon  the  results  so  afforded.  But 
it  is  necessary  that  more  examinations  than  one  should 

117 


CANCER  OF  STOMACH. 


be  made,  and  that  the  circumstances  should  be  changed 
in  some  of  the  examinations.  The  fluids  removed  from 
the  stomach  after  several  hours  of  fasting,  after  a  test 
meal  preceded  by  lavage,  and  after  a  meal  consisting 
chiefly  of  albumens  should  be  examined.  The  charac- 
teristic result  in  cases  of  cancer  shows  absence  of  free 
HCl,  a  diminished  total  acidit}^,  the  presence  of  lactic 
acid,  and  the  presence  of  Oppler-Boas  bacilli.  Briefly 
stated,  my  opinion  is  that  the  early  diagnosis  of  car- 
cinoma of  the  stomach  receives  only  the  slenderest 
help,  if  indeed  it  receives  any,  from  those  examina- 
tions; whereas,  in  the  later  cases,  a  suspicion  of  malig- 
nancy receives  strong  confirmation  if  the  characteristic 
conditions  I  have  named  are  found. 

Conclusions. 

I  would  endeavour  to  sum  up  my  knowledge  of  cancer 
of  the  stomach,  as  revealed  to  me  by  a  study  of  the 
cases  which  have  come  to  me  for  surgical  treatment,  in 
the  following  propositions: 

1.  Cases  of  cancer  of  the  stomach  when  examined  in 
regard  to  their  previous  history  may  be  divided  into 
three  groups:  (a)  Cases,  generally  acute,  in  which  the 
symptoms  appear  suddenly  and  progress  rapidly;  the 
whole  history  may  be  confined  within  a  space  of  four 
to  nine  months.     (6)  Cases  in  which  there  is  a  history 

118 


CANCER  OF  STOMACH. 


of  one  ancient  attack,  or  of  repeated  attacks,  due  un- 
doubtedly to  the  presence  of  a  chronic  gastric  ulcer, 
(c)  Cases  in  which  there  is  no  previous  history  of  gastric 
ulcer;  in  some  of  them  a  condition  of  "ulcus  carcino- 
matosum  '^  may  be  found. 

2.  The  acute  cases  are  not  seldom  ushered  in  by  an 
attack  of  severe  hsematemesis,  with  or  without  melsena. 
It  is  possible  that  such  copious  bleeding  is  dependent 
upon  multiple  haemorrhagic  erosions. 

3.  The  importance  of  a  history  of  repeated  attacks 
of  indigestion,  alike  in  their  origin,  course,  and  termina- 
tion, cannot  be  exaggerated.  Such  attacks  are  due 
to  a  chronic  gastric  ulcer,  which  at  last  becomes  malig- 
nant. 

4.  Cancer  of  the  stomach,  in  so  far  as  it  depends 
upon  a  chronic  ulcer  for  its  origin,  is  a  preventable 
disorder.  It  is  probable  that  two-thirds  of  the  whole 
number  of  cases  may  be  so  classed. 

5.  The  final  attack  is  distinguished  from  former 
attacks  by  its  lingering  character,  its  rebellion  against 
the  treatment,  dietetic  and  medicinal,  which  has 
proved  helpful  before,  but  chiefly  by  the  presence  of  a 
profound  distaste  for  food,  anaemia,  and  a  progressive 
loss  of  weight. 

6.  The  chemical  examination  of  stomach  contents  is 
of  little  or  no  value  in  so  far  as  early  diagnosis  of  car- 

119 


CANCER  OF  STOMACH. 


cinoma  of  the  stomach  is  concerned.  In  the  later 
cases,  when  a  possible  diagnosis  of  malignancy  is  made 
on  the  clinical  evidence,  the  results  of  repeated  chem- 
ical analyses  of  the  stomach  contents  afford  additional 
evidence  of  considerable  value. 

7.  Surgical  treatment  should  be  advised  in  all  cases 
of  stomach  disorder  where  there  is  obstruction,  stasis, 
or  tumour,  and  in  all  cases  of  chronic  ulcer;  in  this  way 
early  cases  of  carcinoma  will  be  found,  and  radical 
treatment  will  be  possible. 

8.  There  are  no  symptoms,  and  there  are  no  signs 
which,  individually  or  collectively,  permit  of  an  as- 
sured diagnosis  of  cancer  of  the  stomach  in  an  early 
stage.  In  cases  where  there  is  grave  suspicion  an 
exploratory  operation  should  be  advised.  Such  opera- 
tions should  be  practised  to  enable  a  diagnosis  to  be 
made  in  an  early  stage,  not  to  conjSrm  an  almost  cer- 
tain diagnosis  in  a  hopeless  stage. 

The  surgical  treatment  of  cancer  of  the  stomach  is 
now  based  upon  sound  principles,  as  a  result  of  the 
work  of  many  labourers  in  different  fields.  When  the 
growth  is  seated  at  or  near  the  pylorus,  or  along  the 
lesser  curvature  of  the  stomach  (and  these  are  the 
cases  we  are  chiefly  considering),  the  anatomical  and 
pathological  investigations  have  indicated  certain 
essentials  to   be  observed  in   order  that   the  whole 

120 


CANCER  OF  STOMACH. 


growth,  and  the  lymphatic  area  in  connexion  with  it, 
may  be  eradicated  in  accordance  with  those  principles 
now  generally  held  to  be  necessary  in  dealing  with  any 
form  of  carcinomatous  disease. 

After  a  study  of  all  the  factors,  we  are  in  a  position  to 
lay  down  the  lines  upon  which  an  operation  for  the 
removal  of  a  malignant  growth  beginning  in  the  pyloric 
region  of  the  stomach  should  be  based.  It  is  essential 
that  the  whole  growi:h  should  be  taken  away,  and  such 
a  margin  beyond  the  visible  and  palpable  tumour  as 
shall  ensure  that  the  outlying  nodules  are  within  the 
lines  of  section;  that  all  the  lesser  curvature,  that  one- 
half  of  the  greater  curvature,  and  that  an  inch  at  least 
of  the  duodenum  should  be  removed;  that  all  the 
"primary"  glands  at  least  should  be  taken  (these  are 
the  lower  and  upper  coronary,  the  right  paracardial, 
the  suprapyloric,  the  right  suprapancreatic,  the  right 
gastro-epiploic,  upper  and  lower,  and  the  retropyloric). 
The  removal  of  all  these  parts  is  possible,  and  therefore 
the  somewhat  mournful  view  of  the  possibilities  of  the 
surgical  treatment  of  cancer  of  the  stomach  taken 
by  several  writers  is  not  justified.  The  difficulties  to 
be  encountered  will  chiefly  lie  in  the  removal  of  the 
right  suprapancreatic  glands,  but  that  these  difficulties 
are  exaggerated  is,  I  think,  quite  certain.  In  several 
cases  I  have,  by  using  the  "gauze  stripping"  method, 

121 


CANCER  OF  STOMACH. 


removed  the  glands  without  any  injury  either  to  the 
hepatic  artery  or  to  the  pancreas. 

The  following  are  the  steps  of  the  operation,  as 
briefly  outlined  as  possible : 

1.  The  free  opening  of  the  abdomen  in  or  near  the 
middle  line;  the  inspection  of  the  parts;  the  packing 
of  swabs  around  the  area  to  be  engaged  in  the  operation, 
so  as  to  avoid  any  soihng  of  the  parts.  Nothing  except 
the  viscera  at  the  moment  engaged  in  the  operation 
should  be  visible. 

2.  Preliminary  ligature  of  the  pyloric,  gastro-duo- 
denal,  and  left  gastro-epiploic  arteries  (not  the  coro- 
nary), division  of  the  gastro-hepatic  omentum  close  to 
the  liver. 

3.  Division  of  the  duodenum  between  clamps,  and 
the  use,  on  the  distal  side,  of  a  suture  to  close  the  duo- 
denum by  infolding.  On  the  proximal  side  the  exposed 
mucosa  is  well  seared  with  the  cautery,  and  a  stitch 
taken  round  the  clamp  to  prevent  it  slipping. 

4.  Ligature  of  the  gastro-hepatic  omentum  below 
all  glands  in  the  greater  curvature.  The  most  im- 
portant point  is  now  to  see  that  the  middle  colic  artery 
is  not  wounded.  The  omentum  is  Hgatured  up  to  a 
point  just  beyond  the  middle  of  the  greater  curvature, 
so  that  all  glands  are  removed. 

5.  The  stomach  is  now  turned  well  over  to  the  left, 

122 


CANCER  OF  STOMACH. 


and  the  coronary  artery  ligatured  at  its  origin  from 
the  coeliac  axis.  At  once  the  lesser  curvature  is  freed, 
and  the  stomach  can  be  pulled  lower.  In  this  way  all 
the  coronary  glands  remain  with  the  stomach. 

6.  Performance  of  posterior  gastro-enterostomy. 
This  is  done  before  the  stomach  is  cut  away,  being  then 
far  easier. 

7.  Division  between  clamps  of  the  stomach  from  the 
oesophagus  at  its  right  margin  to  a  point  a  little  to  the 
left  of  the  middle  of  the  greater  curvature. 

8.  Cauterisation  of  the  exposed  mucosa  of  the  stom- 
ach and  closure  of  the  cut  end  of  the  stomach  by  a 
double  suture. 

9.  Toilet  of  the  peritoneum  and  closure  of  the  parie- 
tal wound. 

The  size  of  the  growth  at  or  near  the  pylorus  has  no 
influence  upon  the  extent  of  the  resection.  For  the 
very  smallest  growth  a  resection  to  this  extent  is 
needed.  If  the  growth  invades  the  body  of  the  stom- 
ach, it  may  involve  the  removal  of  all  of  the  stomach 
but  the  isolated  area,  after  the  manner  described  by 
me  several  years  ago. 

REFERENCES. 

1.  British  Medical  Journal,  1906,  i,  p.  370. 

2.  Annals  of  Surgery,  1908,  xlvii,  p.  889. 

123 


Remarks  Upon  the  Surgery  of  the 
Common  Bile-duct."^ 

The  subject  that  I  have  chosen  for  the  address  which, 
by  your  courtesy,  I  have  the  honour  to  deliver  to-night 
is  ''The  Surgery  of  the  Common  Bile-duct."  Ex- 
perience in  this  branch  of  surgery  has  been  rapidly 
accumulating,  and  a  brief  survey  of  the  work  which 
has  already  been  done  is  not  undesirable.  An  occa- 
sion of  this  kind  affords  a  definite  stimulus  to  a  scrutiny 
of  one's  own  work  and  gives  an  incentive  and  an  oppor- 
tunity both  for  comparison  with  that  of  others  and 
for  a  review  of  the  whole  subject. 

The  common  bile-duct  is  rather  more  than  3  inches 
in  length;  it  extends  from  the  junction  of  the  cystic 
and  common  hepatic  ducts  downwards  and  to  the 
right  in  the  free  edge  of  the  gastro-hepatic  omentum 
to  its  termination  in  the  second  portion  of  the  duo- 
denum, where  it  bears  a  relationship  to  the  opening  of 
the  canal  of  Wirsung,  the  duct  of  the  pancreas.     As  a 

*An  address  delivered  before  the  Nottingham  Medico- 
Chirurgical  Society  on  Oct.  18,  1905,  and  reprinted  from  the 
Lancet,  Jan.  20,  1906. 

125 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

rule,  three  portions  of  the  duct  are  described:  (1)  the 
supra-duodenal  portion;  (2)  the  retro-duodenal  por- 
tion, or  the  pancreatic  portion;  and  (3)  the  trans- 
duodenal portion. 

1.  The  supra-duodenal  portion  varies  from  134  to 
13^2  inches  in  length.  It  lies  in  the  free  edge  of  the 
gastro-hepatic  omentum,  having  the  hepatic  artery  to 
the  left  and  the  portal  vein  behind.  It  is  the  widest 
part  of  the  duct,  which  in  its  whole  course  is  funnel- 
shaped,  gradually  narrowing  from  its  origin  to  its 
termination.  The  point  of  chief  surgical  importance  is 
the  fact  that  along  this  portion  of  the  duct  three  or  four 
lymphatic  glands  he.  These  in  their  enlargement  may 
come  to  resemble  stones;  indeed,  they  cannot  always 
be  distinguished  from  stones  by  touch  alone. 

2.  The  retro-duodenal  portion  is  from  1  inch  to  IJ^ 
inches  in  length.  It  is  in  close  relationship  with  the 
pancreas,  lying  either  in  a  groove  in  the  gland  or  actu- 
ally traversing  its  substance.  Helly  in  40  cases  found 
that  the  duct  lay  in  a  groove  in  15  cases  and  was  em- 
bedded in  the  gland  in  25.  Bunger  in  58  cases  found 
that  in  55  the  duct  was  embedded,  in  three  only  was 
it  partially  uncovered  by  the  pancreas. 

3.  The  trans-duodenal  portion,  about  from  3^  to  J^ 
of  an  inch  in  length,  consists  of  that  portion  of  the  duct 
which  Hes  within  the  wall  of  the  duodenum.     In  order 

126 


SURGERY  OF  THE  COMMON  BILE-DUCT. 


to  open  the  lumen  of  this  portion  of  the  duct  from 
within  the  duodenum  the  wall  of  the  bowel  has  there- 
fore to  be  cut  into  but  not  through. 

The  common  duct  at  its  termination  in  the  duodenum 
is  associated  with  the  termination  of  the  duct  of  Wir- 
sung  in  a  manner  that  is  liable  to  variation.  The  two 
ducts  are  surrounded  by  a  circular  band  of  muscular 
fibres  described  as  the  ''sphincter  of  Oddi."  Letulle 
and  Nattan-Larrier  described  four  varieties  in  the 
mode  of  ending  of  the  common  bile-duct  and  of  the 
pancreatic  duct  in  the  duodenum.  First  type  (2  cases 
in  21) :  There  is  a  complete  absence  of  any  projection 
or  raising  up  of  the  mucosa.  A  longitudinal  furrow 
from  2  to  3  millimetres  long,  with  prominent  Hps, 
surrounding  a  circular  or  oval  opening,  is  seen.  This 
opening  is  the  termination  of  the  common  duct.  The 
canal  of  Wirsung  opens  into  the  common  duct  at  a 
variable  distance  from  the  intestine.  Second  type 
(6  cases  in  21):  it  forms  the  ''perfect  model  of  the 
ampulla  of  Vater."  At  the  opening  into  the  intestine 
there  is  a  shght  projection  on  the  surface  of  the  mucosa, 
from  7  to  12  millimetres  in  length.  The  opening  is 
circular  or  elongated  vertically,  and  at  its  largest 
measures  3  milUmetres  in  length.  The  two  ducts 
terminate  in  a  cavity  more  or  less  circular,  the  measure- 
ments of  which  are,  in  a  vertical  direction,  from  4  to 

127 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

6  millimetres,  and  in  the  transverse  from  6  to  7  milli- 
metres. Before  opening  into  the  ampulla  both  ducts 
are  narrowed  for  a  few  millimetres.  As  a  rule,  the 
common  duct  lies  near  to  the  duodenum  in  this  type 
and  can  be  felt  as  a  vertical  ridge  beneath  the  mucosa. 
Third  type  (8  cases  in  21) :  This  form  is  characterised 
by  the  presence  of  a  very  slight  elevation  on  the  sur- 
face of  the  duodenum,  by  a  shallow  fossa  or  gutter 
situated  immediately  below  the  point  of  opening  of  the 
ducts,  and  by  the  non-confluence  of  the  two  ducts 
before  their  termination.  There  is,  therefore,  no 
ampulla.  The  extent  of  the  gutter  or  trough  which 
surrounds  the  lower  parts  of  the  ducts  at  their  termina- 
tions varies  very  greatly  in  different  cases.  The  two 
ducts  lie  together  at  their  termination  like  the  two 
barrels  of  a  gun;  the  pancreatic  duct  may  be  below 
and  behind  or  below  and  in  front  of  the  common  duct. 
Fourth  type  (4  cases  in  21):  In  this  form  there  is  a 
prominent  papillary  projection,  on  the  summit  of 
which  the  two  ducts  open  side  by  side,  separated  by  a 
vertical  partition;  there  is  no  ampulla.  In  some  cases 
the  opening  of  the  canal  of  Wirsung  may  be  crescent- 
shaped,  the  opening  of  the  common  duct  lying  in  the 
hollow  of  the  crescent.  It  will  be  seen  that  from  the 
surgical  point  of  view  it  is  a  matter  of  the  greatest  im- 
portance to  recognise  these  varieties  of  form;   the  ob- 

128 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

struction  of  the  lower  part  of  the  duct  in  the  first 
variety  would  involve  an  implication  of  the  pancreas; 
the  obstruction  of  the  orifice  of  the  ampulla  in  the 
second  variety  would  convert  the  common  duct  and 
the  canal  of  Wirsung  into  a  single  channel,  whereas  in 
the  third  and  fourth  forms  the  ducts  are  strictly  sepa- 
rate. The  conditions  in  which  surgical  interference 
with  the  common  duct  is  called  for  are:  (1)  rupture  of 
the  duct;  (2)  calculus  and  in  inflammatory  conditions 
caused  by  other  agents;  (3)  stricture;  (4)  new  gro^iih; 
and  (5)  pressure  upon  the  duct  from  without. 

1.  Rupture  of  the  Common  Bile-duct. 

Rupture  of  the  common  bile-duct  may  be  the  result 
of  injury  or  of  disease, 

{a)  Traumatic  rupture  of  the  common  duct  is  always 
subcutaneous;  so  far  as  I  am  aware  no  case  has  been 
recorded  as  the  result  of  a  penetrating  wound.  Trau- 
matic subcutaneous  rupture  probably  occurs  more 
frequently  than  the  recorded  cases  would  lead  one  to 
believe.  The  number  of  the  cases  in  which  a  laceration 
or  rupture  of  the  duct  has  been  discovered  either  during 
an  operation  or  upon  post-mortem  examination  is 
small,  but  cases  similar  in  all  the  details  of  their  clin- 
ical history  to  these  have  recovered  after  the  abdomen 
has  been  aspirated  and  large  quantities  of  bile  or  deeply 
9  129 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

bile-stained  fluid  have  been  evacuated.  A  rupture  of 
the  duct  in  these  instances,  though,  of  course,  not 
certain,  was  at  the  least  extremely  probable.  The 
bile-duct  may  be  torn  at  any  part  of  its  course  and  the 
rent  may  be  small  or  the  duct  may  be  completely 
severed.  The  laceration,  when  small  in  size,  may  in- 
volve the  anterior  or  the  posterior  wall;  a  large  tear 
or  a  complete  division  of  the  duct  is  the  condition 
generally  found.  As  soon  as  the  duct  is  torn,  bile 
escapes  into  the  peritoneal  cavity  and  before  long  sets 
up  a  responsive  peritonitis.  The  result  is  that  in  the 
earliest  days  a  very  copious  deposit  of  lymph  is  found 
in  all  the  parts  in  the  neighbourhood  of  the  duct.  The 
under  surface  of  the  liver  is  plastered  with  thick  layers 
of  lymph,  the  intestines,  the  duodenum,  and  the  stom- 
ach especially,  are  all  coated  over  with  lymph,  which 
can  be  peeled  off  in  thick  strips.  The  bile  escaping 
from  the  duct  may  run  free  in  the  peritoneal  cavity  or 
its  passage  may  be  checked  by  barriers  of  lymph;  an 
encysted  swelling  then  results.  It  is  interesting  to 
note  that  this  abundant  deposit  of  lymph  occurs  only, 
or  at  least  chiefly,  after  a  traumatic  rupture  of  the 
common  duct.  When  the  hepatic  duct  or  the  gall- 
bladder is  torn,  lymph  is  formed  in  most  cases,  but 
neither  so  rapidly  nor  so  freely  as  when  the  common 
duct  is  involved.     The  reason  for  this  may  be  found  in 

130 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

the  different  condition  of  the  bile  as  regards  the  pres- 
ence of  micro-organisms.  Gilbert  and  Lippmann^ 
investigated  the  condition,  so  far  as  concerned  micro- 
organisms, of  the  bile  in  the  extra-hepatic  ducts  in 
animals.  The  middle  and  lower  thirds  of  the  common 
duct  were  found  to  contain  both  aerobic  (including 
the  bacillus  coli  communis)  and  anaerobic  organisms, 
but  in  the  cystic  duct  and  gall-bladder,  only  anaerobic 
organisms  were  found.  The  numbers  of  these  or- 
ganisms diminished  gradually  towards  the  upper  part 
of  the  hepatic  duct.  It  seemed  clear  that  the  infection 
of  the  bile-passages  proceeded  upwards  from  the  in- 
testine. Bile  poured  out,  therefore,  from  either  the 
hepatic  duct  or  the  gall-bladder  would  prove  less  irri- 
tating to  the  peritoneum  than  that  escaping  from  the 
common  duct,  and  would  call  forth  a  less  vigourous 
response  from  it.  This  abundant  deposit  of  lymph 
prevents  the  resorption  of  bile  by  the  peritoneum. 
But  for  this  the  bile  would  be  rapidly  absorbed  and 
give  rise  to  symptoms  of  toxaemia.  In  a  series  of  ex- 
periments upon  dogs  Erhardt  ligatured  the  common 
duct  immediately  above  the  duodenum  and,  from  the 
ligature,  slit  the  duct  upwards  to  the  hepatic  duct. 
The  animals  died  within  from  two  to  six  days  from  deep 
jaundice  and  profound  symptoms  of  toxaemia.  No 
evidences  of  peritonitis  were  present.     The  bile  ab- 

131 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

sorbed  rapidly  by  the  peritoneum  caused  death  from 
poisoning,  the  harmful  constituents  of  the  bile  being, 
according  to  Biedl  and  Kraus,  the  bile-acid  salts. 
In  Erhardt's  experiments  it  was  found  that  if  at  the 
time  of  the  operation  a  culture  of  the  bacillus  coli  was 
introduced  into  the  peritoneum,  a  plastic  peritonitis 
resulted.  Bile  was  therefore  absorbed  far  more  slowly, 
jaundice  was  slight  and  slow  in  appearing,  and  the 
animals  survived  for  fourteen  days  or  longer.  It  would 
appear,  therefore,  that  in  rupture  of  any  part  of  the 
bile-passages  two  dangers  are  to  be  apprehended — one 
from  the  absorption  of  the  bile  the  acid  salts  of  which 
are  poisonous,  the  other  from  infection  by  organisms 
escaping  through  the  distal  torn  end  and  coming  from 
the  duodenum.  These  organisms,  in  so  far  as  they 
excite  a  fibrinous  peritonitis,  are  helpful  rather  than 
harmful.  It  is  interesting  to  note  that  suppurative 
peritonitis,  either  general  or  local,  has  not  been  ob- 
served in  any  case  so  far  recorded.  Infection  with 
organisms  (probably  the  bacillus  coli)  is  therefore 
slight.  The  deposit  of  lymph  upon  and  around  the 
common  duct  may  cause  the  complete  sealing  up  of 
the  rent,  so  that  when  an  operation  is  performed  no 
further  escape  of  bile  is  perceived  and  the  source  of  that 
which  has  already  escaped  may  be  difficult  to  discover. 
In  Battle's  case,  for  example,  the  laceration  was  hard 

132 


SURGERY  OF  THE  COMMON  BILE-DUCT. 


to  find  post  mortem  on  account  of  this  coating  of  the 
parts  with  lymph.     In  one  case  of  rupture  of  some  part 
of   the   bile-passages    Routier   opened   the   abdomen, 
drained  away  all  the  deeply  bile-stained  fluid,  and  found 
the  under  surface  of  the  liver  and  gall-bladder  and  all 
the  region  of  the  ducts  firmly  surrounded  by  thick 
deposits  of  lymph.     No  bile  could  be  seen  to  issue 
from  any  point.     After  thoroughly  drying  the  peri- 
toneum with  swabs,  Routier  closed  the  abdomen  com- 
pletely and  the  child  made  a  perfect  recovery.     The 
detailed  history  in  this  case  shows  unquestionably  that 
a  rupture  of  the  bile-passages  had  occurred,  and  affords 
a  proof  seemingly  conclusive  that  the  secure  healing  of 
a  duct  may  be  accompHshed  through  the  agency  of  the 
lymph.     A  case  is  recorded  by  Thompson,  of  Edin- 
burgh, in  his  work  on  ''Diseases  of  the  Liver,"  in  which 
the  bile-passages  at  some  part  would  seem  to  have  been 
ruptured.     After  the  usual   course  of  symptoms  the 
abdomen  was  tapped  and  16  pints  of  bile  were  with- 
drawn.    At  the  post-mortem  examination  no  lesion  of 
the  bile-passages   or   of  the   liver   was   discoverable. 
There  was  a  new  ''false  membrane"  covering  the  ducts 
and  lymph  was  deposited  everywhere. 

Symptoms. — The  symptoms  and  signs  caused  by  a 
rupture  of  the  common  bile-duct  are  jaundice,  the 
absence  of  bile  in  the  stools,  the  gradual  distension  of 

133 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

the  abdomen  by  fluid,  and  wasting.  In  2  cases  out  of 
the  total  number  of  12  recorded,  death  occurred  from 
shock  or  collapse  when  no  symptoms  of  any  kind  other 
than  these  had  had  time  to  develop.  The  patients  were 
almost  all  young  children,  only  4  being  over  twenty 
years  of  age  and  5  being  under  six  years  of  age.  The 
accident  was  generally  due  to  the  patient  being  run 
over,  or  kicked,  or  struck  in  the  abdomen.  Jaundice 
is  a  variable  symptom;  it  may  come  on  within  the 
first  few  days  or  its  appearance  may  be  delayed  for  a 
fortnight.  In  at  least  one  case,  that  of  Hahn,  it  was 
never  present.  In  Porter's  case  and  in  Stierlin's  jaun- 
dice disappeared  after  the  abdomen  had  been  tapped 
and  a  large  quantity  of  bile  evacuated.  The  jaundice 
is  never  profound;  in  most  of  the  records  it  is  stated 
that  the  jaundice  was  ''slight''  or  that  the  skin  was 
''lemon  coloured."  The  colouring  of  the  skin  is  due 
to  the  absorption  of  bile  by  the  peritoneum.  As  soon 
as  lymph  is  poured  out,  the  absorption  ceases  or  is 
reduced  considerably,  and  the  jaundice  then  remains 
stationary  or  fades  slowly  away. 

Bile  is  absent  from  the  faeces  in  all  cases  of  rupture 
of  the  common  duct.  All  the  bile  passing  down  the 
duct  escapes  at  the  point  of  rupture.  Though  these 
statements  are  accurate  in  so  far  as  they  concern  the 
cases  in  which  the  presence  of  a  laceration  of  the  duct 

134 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

has  been  verified  by  operation  or  by  post-mortem 
examination,  it  cannot  be  open  to  doubt  that  in  some 
cases  a  rent  in  the  duct  has  been  closed  by  the  deposit 
of  lymph  and  the  patency  of  the  canal  restored.  The 
case  of  Routier,  quoted  above,  is  possibly  one  exemplary 
instance  of  this.  In  the  records  of  the  12  verified  cases 
it  is  noticed  that  the  stools  were  ''clay-coloured," 
"pale  grey,"  or  "alcoholic"  in  9;  in  1  no  record  was 
made,  and  in  2  death  occurred  from  shock  too  early  to 
admit  of  any  observations  upon  this  point.  During 
the  time  that  jaundice  is  present  there  may  be  bile  in 
the  urine,  though  this  is  not  necessarily  the  case.  The 
bile,  though  unable  to  reach  the  intestine,  does  not 
necessarily  become  absorbed  by  the  peritoneum  to  an 
extent  sufficient  to  cause  either  jaundice  or  staining 
of  the  urine. 

The  gradual  distension  of  the  abdomen  by  fluid  is  a 
constant  feature  in  all  cases.  In  10  of  the  12  cases  (2 
patients  dying  from  shock)  a  slow  accumulation  of 
fluid  in  the  abdomen  was  observed.  The  fluid  when 
aspirated  was  found  always  to  be  bile  or  fluid  deeply 
bile-stained.  The  bile  escaping  into  the  peritoneum 
may  flow  over  the  whole  cavity  and  fill  every  part  of 
it,  as  does  the  fluid  in  a  case  of  ascites.  Or  if  the  sero- 
fibrinous peritonitis  be  rapidly  set  up,  barriers  of  lymph 
may  confine  the  fluid  to  a  limited  area  of  the  abdomen, 

135 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

the  rest  being  free.  A  local  swelling,  generally  in  the 
right  hypochondrium,  then  results.  In  one  case 
(Drysdale's)  the  fluid  filled  the  right  side  of  the  ab- 
domen and  the  greater  part  of  the  pelvis,  and  the  wall 
of  lymph  was  so  firm  and  so  complete  that  the  recorder 
speaks  of  a  ''cyst,"  into  which  the  common  duct 
opened  at  the  point  of  rupture. 

A  rapid  loss  of  flesh  is  noted  as  having  occurred 
in  most  of  the  cases,  and  in  some  the  emaciation  is 
spoken  of  as  being  ''extreme."  The  temperature  is 
generally  normal,  increasingly  worse  as  the  abdomen 
enlarges. 

So  far  as  the  differential  diagnosis  is  concerned,  it 
would  seem  that  an  accurate  discrimination  between 
rupture  of  the  hepatic  or  common  ducts  and  rupture 
of  the  gall-bladder  should  be  possible.  When  either 
of  these  ducts  is  torn,  the  whole  of  the  bile  escapes  into 
the  peritoneal  cavity  and  the  stools  are  colourless;  if 
the  gall-bladder  be  torn,  bile  can  still  flow  unhindered 
along  the  ducts  into  the  intestine,  and  the  colour  of  the 
stools  is  normal  or,  owing  to  the  escape  of  a  part  of  the 
bile  through  the  gall-bladder,  is  only  slightly  paler  than 
is  natural. 

Treatment. — In  all  the  cases  so  far  recorded  no  treat- 
ment has  been  adopted  in  the  days  immediately  fol- 
lowing the  accident.     It  is  only  when  the  abdomen  has 

136 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

become  greatly  distended  by  fluid  that  aspiration  or 
incision  has  been  contemplated.  In  one  case,  that 
recorded  by  Rose,  no  less  a  period  than  nine  months 
elapsed  between  the  receipt  of  the  injury  and  the 
operation.  If  the  circumstances  were  such  that  a 
diagnosis  could  be  made  early  and  operation  under- 
taken promptly,  the  results  would  be  more  satisfactory 
than  they  are,  but  the  injury  received  is  rarely  such 
as  to  do  damage  to  other  parts  than  the  common  duct, 
the  shock  and  collapse  pass  off  rapidly,  and  the  general 
and  local  conditions  improve  so  decidedly  that  no 
question  of  surgical  treatment  arises.  It  is  only  when 
jaundice,  faecal  acholia,  and,  above  all,  the  general 
distension  of  the  abdomen,  are  recognised  that  the 
diagnosis  is  assured.  If  early  operation  could  be 
performed,  then  end-to-end  suture,  or  partial  suture 
with  drainage,  as  in  choledochotomy,  might  be  per- 
formed. In  some  of  the  cases — Porter's  and  Stier- 
lin's — the  distal  end  of  the  common  duct  could  not  be 
found  even  after  the  most  careful  search;  in  Stierlin's 
case,  indeed,  the  distal  end  could  not  be  discovered 
even  at  the  post-mortem  examination.  In  such  cir- 
cumstances ligature  of  the  proximal  end  of  the  duct 
and  cholecystenterostomy  might  be  performed,  or  the 
proximal  end  of  the  duct  might  be  implanted  into  the 
duodenum.     In  those  cases  in  which  the  conditions 

137 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

are  so  serious  that  the  simplest  and  speediest  operation 
is  alone  permissible  the  bile  must  be  emptied  out  as 
thoroughly  as  possible  and  a  large  drainage-tube  be 
introduced.  Courvoisier  suggested  that  when  the 
common  duct  was  completely  ruptured,  tubes  might 
be  passed  into  each  torn  end  and  left  hanging  out  from 
the  abdominal  incision.  When  adhesions  around  the 
tubes  had  shut  them  off  from  the  general  peritoneal 
cavity,  the  tubes  could  be  removed  and  the  bile  might 
then  find  its  way  from  the  upper  to  the  lower  opening 
and  the  biliary  fistula  gradually  close. 

(6)  Pathological  rupture  of  the  common  bile-duct  occurs 
generally  as  the  result  of  the  presence  of  a  foreign 
body.  Inflammation,  softening  and  distension  of  the 
walls,  and  finally  ulceration  are  set  up  and  the  duct 
at  last  gives  way.  The  rupture  of  the  duct  may 
occur  into  the  general  peritoneal  cavity;  or  into  a 
localised  mass  of  protective  adhesions,  an  abscess  then 
resulting;  or  the  outer  surface  of  the  duct  before 
rupture  occurs  may  have  become  strongly  adherent  to 
a  neighbouring  viscus  into  which  the  perforation  takes 
place,  with  the  formation  of  a  fistula. 

Including  the  cases  collected  by  Courvoisier,  there 
are  11  instances  of  perforation  of  the  common  bile-duct 
into  the  general  peritoneal  cavity;  in  6  cases  stones  were 
present,  in  3  ascarides,  and  in  2  no  foreign  body  could 

138 


SURGERY  OF  THE  COMMON  BILE-DUCT. 


be  found.  In  all  the  clinical  course  was  rapid  and 
death  occurred  from  acute  peritonitis;  in  one  case  there 
was  profuse  haemorrhage,  possibly  from  ulceration  into 
the  portal  vein.  An  interesting  example  of  rupture 
of  the  common  duct  into  the  peritoneal  cavity,  causing 
death  from  peritonitis,  is  recorded  by  Janeway.^  In 
some  cases  the  perforation  of  the  duct  is  subacute,  an 
abscess  being  slowly  developed.  The  spreading  of  this 
gives  rise  occasionally  to  a  subphrenic  abscess,  or  the 
local  abscess  may  rupture  and  cause  a  diffuse  septic 
peritonitis,  or  the  abscess  may  open  secondarily  into 
the  colon^  or  upon  the  abdominal  wall,  an  external 
biliary  fistula  being  formed.^ 

When  the  common  duct  has  become  adherent  to  a 
hollow  viscus  or  the  perforation  has  occurred  from  the 
third  portion  of  the  duct,  a  fistula  results.  I  have 
operated  upon  fistulse  connecting  the  common  duct 
and  the  gall-bladder  and  the  common  duct  and  the 
duodenum.  A  choledocho-duodenal  fistula  may  con- 
nect the  second  or  the  third  part  of  the  duct  with  the 
bowel.  The  ''wide-mouthed  opening"  of  the  common 
duct  into  the  duodenum  seen  in  cases  of  old-standing 
obstruction  of  the  duct  by  a  calculus  is  in  reality  the 
opening  of  a  fistula  through  which  the  stone  has  ul- 
cerated into  the  bowel. 


139 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

2.  Stone  in  the  Common  Duct. 

A  stone  lodged  in  the  common  duct  causes  an  ob- 
struction which  is  either  complete  or  incomplete:  com- 
plete when  the  stone  has  just  entered  the  duct,  which 
it  fits  tightly,  preventing  any  drop  of  bile  from  passing 
it,  incomplete  when  the  stone  has  been  in  the  duct  for 
some  weeks  or  months,  when  secondary  changes  in  the 
duct,  such  as  softening  and  dilatation,  have  occurred, 
and  when,  therefore,  the  stone  no  longer  fits  the  duct 
tightly  but  lies  loosely  within  it,  permitting  the  escape 
of  bile  by  its  side.  In  other  words,  an  acute  obstruc- 
tion of  the  duct  is  complete  and  a  chronic  obstruction 
is  incomplete.  In  the  majority  of  cases  of  calculous 
occlusion  of  the  duct  there  are  more  stones  than  one. 
Courvoisier  in  149  cases  found  that  there  was  a  single 
calculus  in  95,  that  there  were  two  calculi  in  36,  and 
that  there  were  12  stones  or  more  in  18  cases.  The 
experience  of  most  surgeons,  however,  is  different  from 
this.  When  choledochotomy  is  performed,  a  solitary 
stone  is  found  in  only  about  1  case  in  4.  Courvoisier 
in  123  cases  found  that  the  position  of  the  stone  or 
stones  blocking  the  duct  was  as  follows:  in  17  cases  at 
the  commencement  of  the  duct;  in  19  cases  in  the 
middle  of  the  duct;  in  20  cases  near  the  duodenum 
(retro-duodenal  portion);   in  41  cases  at  the  ampulla; 

140 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

and  in  26  cases  the  whole  length  of  the  duct  was  blocked. 
Vautrin  in  47  cases  found  that  calculi  were  present 
in  the  part  of  the  common  duct  above  the  duodenum 
in  27  cases;  in  the  duct  in  contact  with  the  duodenum 
in  18  cases;  and  in  the  ampulla  in  2  cases.  In  some 
rare  cases  the  whole  of  the  common  duct,  from  end  to 
end,  the  hepatic  duct,  and  all  the  intrahepatic  ducts 
may  be  filled  with  stones  very  tightly  packed  together 
or  with  a  sort  of  thick,  tenacious  mucus  containing 
gall-stones  innumerable. 

Acute  occlusion  of  the  common  duct  from  within  is 
rare,  except  as  a  transient  condition.  When  a  gall- 
stone escapes  into  the  common  duct  from  the  cystic 
duct  it  passes  at  once  downwards  into  the  funnel- 
shaped  duct  as  far  as  it  can  before  it  is  arrested.  The 
larger  a  stone  is,  the  sooner  will  progress  be  checked; 
the  smaller  a  stone,  the  further  will  it  pass.  When  a 
part  of  the  duct  is  reached  the  lumen  of  which  is  so 
narrow  that  the  stone  cannot  pass,  it  is  arrested.  It 
then  fills  the  duct  and  blocks  its  lumen  absolutely, 
allowing  no  drop  of  bile  to  escape  by  its  side.  The 
common  duct  is  then  as  securely  blocked  as  if  tied  with 
a  string.  But  this  condition  of  things  does  not  long 
endure.  Slowly  but  surely  certain  changes  occur,  the 
result  of  inflammation  in  the  duct,  softening  of  its 
walls,  and  the  secretion  pressure  of  the  bile,  which  have 

141 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

the  effect  of  giving  rise  to  a  dilatation  of  the  duct,  so 
that  a  stone  which  at  first  fitted  tightly  now  fits  loosely. 
The  stone  forms,  as  Fenger  first  pointed  out,  a  sort 
of  ''ball-valve"  in  the  duct.  A  complete  occlusion  of 
the  duct  is,  therefore,  in  cases  of  stones,  only  an  acute 
temporary  condition.  As  the  result  of  inevitable 
changes  in  the  duct  the  obstruction  becomes  only  a 
partial,  incomplete  one.  In  cases  of  stricture,  simple 
or  malignant,  or  of  compression  of  the  duct  from  with- 
out by  enlarged  glands  or  by  the  head  of  the  pancreas 
involved  in  a  carcinomatous  growth,  the  complete 
obstruction  of  the  duct  may  be  permanent.  A  stricture 
of  the  duct  may  cause  its  absolute  obliteration  for 
a  space  of  an  inch  or  more;  in  such  a  state  the  occlusion 
is  complete  and  permanent.  In  all  cases  where  the 
block  in  the  duct  is  complete  the  bile  pent  up  behind 
the  obstruction  becomes  gradually  absorbed  and  the 
hepatic  ducts  and  all  the  biliary  ducts  behind  the 
occlusion  become  filled  with  clear,  sticky  mucus.  The 
ducts  are  everywhere  dilated. 

The  chief,  and  often  the  only,  symptom  of  complete 
closure  of  the  common  duct  is  jaundice,  deep  and 
unchanging.  In  the  earliest  stages  when  the  obstruc- 
tion is  developing  pain  may  be  present,  but  it  is  rarely 
or  never  severe  and  it  disappears  speedily.  Jaundice 
in  cases  of  obstruction  by  stone  appears  rapidly  and 

142 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

attains  its  maximum  within  a  few  days;  in  cases  of 
obstruction  of  the  duct  due  to  stricture,  simple  or 
malignant,  or  to  compression  by  growth  from  with- 
out, the  jaundice  comes  insidiously,  deepens  little  by 
little,  never  lessens,  but  progresses  always  to  its  maxi- 
mum intensity  without  any  periods  of  remission.  It 
is  in  these  cases  of  complete  obstruction  of  the  duct 
that  the  diagnosis  is  difficult  and  at  times  even  im- 
possible. If  time  elapses  without  any  onset  of  rigors 
or  of  variation  in  the  jaundice,  the  likelihood  of  a  stone 
being  present  is  small ;  the  obstruction  then  is  probably 
due  to  malignant  disease  in  or  around  the  duct. 

The  condition  of  the  gall-bladder  in  these  cases 
affords  a  great  help  in  achieving  an  accurate  diagnosis. 
This  point  was  first  fully  investigated  by  Courvoisier. 
He  found  in  187  cases  of  obstruction  of  the  common 
duct  that  in  100  the  obstruction  was  due  to  causes  other 
than  stone,  and  in  87  to  the  impaction  of  a  stone.  Of 
the  100  cases  in  which  the  obstruction  was  due  to 
causes  other  than  stone,  in  92  there  was  dilatation  of 
the  gall-bladder  and  in  8  cases  there  was  a  normal  gall- 
bladder or  an  atrophy  of  the  gall-bladder.  Of  87  cases 
in  which  the  obstruction  was  due  to  stone,  in  70  cases 
the  gall-bladder  was  atrophied  and  in  17  cases  the  gall- 
bladder was  dilated.  All  these  cases  were  collected 
from  the  literature.     Of  the  cases  that  came  to  opera- 

143 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

tion  and  were  recorded  by  Courvoisier,  35  in  number, 
in  18  the  obstruction  was  due  to  causes  other  than 
stone,  and  in  16  of  these  there  was  dilatation  of  the 
gall-bladder,  in  17  the  obstruction  was  due  to  stone, 
and  in  13  of  these  the  gall-bladder  was  contracted. 
These  observations  of  Courvoisier  were  formulated 
by  him  in  the  following  statement,  which  is  now  gen- 
erally referred  to  as  "  Courvoisier's  law."  ^^In  cases  of 
chronic  jaundice  due  to  blocking  of  the  common  duct,  a 
contraction  of  the  gall-bladder  signifies  that  the  obstruction 
is  due  to  stone;  a  dilatation  of  the  gall-bladder,  that  the 
obstruction  is  due  to  causes  other  than  stone."  The 
validity  of  this  law  has  been  closely  investigated  and 
its  truth  has  been  affirmed  by  almost  every  writer. 
Ecklin  in  172  cases  of  common  duct  obstruction  due  to 
calculus  found  that  28,  or  16  per  cent.,  had  dilatation 
of  the  gall-bladder,  and  144,  or  84  per  cent.,  had  con- 
traction of  the  gall-bladder.  In  139  cases  of  obstruction 
due  to  other  causes  121,  or  87  per  cent.,  had  dilatation 
of  the  gall-bladder. 

A  further  examination  of  the  question  has  been  made 
by  Dr.  A.  Cabot,  of  Boston,  who  collected  the  records 
of  the  Massachusetts  Hospital.  There  were  86  cases 
of  obstruction  of  the  common  duct.  Of  these,  57  were 
due  to  obstruction  by  stone;  in  47  the  gall-bladder  was 
atrophied,  in  8  it  was  normal,  and  in  2  enlarged;   29 

144 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

cases  were  due  to  causes  other  than  stone;  in  27  the 
gall-bladder  was  distended,  in  1  the  gall-bladder  was 
empty,  and  in  1  contracted  around  three  stones.  Only 
4  cases,  therefore,  in  this  series  did  not  fall  in  with 
Courvoisier's  law.  Cabot  writes:  ''With  the  exception 
of  these  4  cases,  which  constitute  only  5  per  cent,  of 
the  total  number  examined,  every  record  of  the  Massa- 
chusetts Hospital  series  in  which  definite  statements  are 
to  be  found  concerning  the  points  at  issue  goes  to 
confirm  Courvoisier's  law."  The  explanation  given 
by  Courvoisier  of  the  occurrence  of  sclerosis  of  the 
gall-bladder  in  cases  of  stone  was  that  the  presence  of 
calculi  in  the  gall-bladder  and  their  passage  or  at- 
tempted passage  down  the  ducts  had  caused  irritation 
and  inflammation  in  and  around  the  bile-passage. 
Cholecystitis  and  peritonitis  were  the  result  and  had 
determined  the  cicatricial  cramping  and  compression 
of  the  gall-bladder. 

If  persistent  and  unvarying  jaundice  is  associated 
with  enlargement  of  the  gall-bladder,  and  inflammatory 
troubles,  rigors,  sweatings,  elevation  of  temperature, 
and  rapidity  of  pulse  are  also  in  evidence,  then  it  is 
probable  that  there  is  a  stone  in  the  common  duct  and 
that  cholangitis  and  cholecystitis  are  secondary  to  it, 
for  infection  of  the  bile-passages,  though  not  impossible 
in  cases  of  malignant  disease,  occurs  far  less  frequently 
10  145 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

than  when  the  obstruction  is  calculous.  The  presence 
of  enlargement  of  the  liver,  especially  of  an  irregular 
character,  or  of  ascites  will  support  a  diagnosis  of 
carcinoma. 

Incomplete  Occlusion  of  the  Common  Duct;    Chronic 
Calculous  Obstruction. — In  the  great  majority  of  cases 
of  obstruction  of  the  common  duct  by  stone  the  block 
is  only  a  partial  and  intermittent  one.     At  the  first 
the  occlusion,  as  I  have  pointed  out,  is  complete,  but 
after  a  time  the  stone  is  loosened  and  comes  to  act  as  a 
ball-valve.     It  then  floats  in  the  duct,  upwards  and 
downwards.     At  times  it  is  pressed  onwards,  in  part, 
perhaps,  by  the  force  of  the  bile  behind  it,  in  part  also 
by  the  muscular  contraction  of  the  walls  of  the  duct. 
As  it  passes  further  downwards  it  comes  to  a  part  of 
the  duct  whose  lumen  is  not  large  enough  to  permit  the 
further  descent  of  the  calculus.     The  stone  is  arrested 
there,  gripped  firmly,  and  for  a  time  the  block  in  the 
duct  again  becomes  complete.     Soon,   however,   the 
stone  is  fioated  upwards  into  the  wider  duct  and  bile 
escapes  past  it  into  the  lower  part  of  the  duct  to  flow 
into  the  duodenum.     The  occlusion  is  then  incomplete 
and  remains  so  until  the  stone  again  attempts  to  pass 
downwards  and  is  again  arrested.     The   description 
given  by  Fenger  of  the  ''ball-valve"  action  of  the  stone 
is  thus  seen  to  be  completely  justified,  for  at  times  the 

146 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

passage  of  bile  is  absolutely  stopped  by  the  stone  and 
at  other  times  the  bile  can  flow  past  the  stone  un- 
hindered. The  fact  that  the  stone  lies  freely  moveable 
in  a  dilated  duct  is  always  realised  by  the  surgeon  in 
the  operation  of  choledochotomy,  for  it  is  difficult 
to  fix  the  stone,  owing  to  the  ease  with  which  it  slips 
away  from  the  grasp  of  the  fingers. 

The  symptoms  of  stone  in  the  common  duct  are 
sometimes  trivial  and  inconspicuous  and,  indeed,  are 
at  times  entirely  absent.  I  have  twice  found  during 
the  performance  of  cholecystotomy  that  stones  were 
present  in  the  common  duct  when  symptoms  were 
wholly  lacking.  If  the  stone  is  small  or  fits  loosely  in 
the  duct,  there  may  be  neither  obstruction  nor  cholan- 
gitis, and  the  stone,  therefore,  may  never  attract  clinical 
recognition.  The  symptoms  are  due  in  part  to  the 
intermittent  mechanical  impediment  in  the  duct  and 
in  part  to  the  cholangitis  which  the  stones  excite. 

Pain  is  present  only  at  times.  It  comes,  as  a  rule, 
in  attacks  which  vary  much  in  severity.  The  pain  is 
dull  and  aching  with,  especially  in  the  beginning  of  the 
attack,  spasmodic  outbursts.  As  a  rule  the  pain  is 
accompanied  by  a  rigor;  the  temperature  runs  rapidly 
up  to  102°,  103°,  or  104°  F.;  there  are  shivering  and 
collapse,  followed  by  sweating,  and  in  the  succeeding 
hours  it  is  noticed  that  the  jaundice,  which  is  persis- 

147 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

tent,  has  deepened  much  in  tinge.  In  the  intervals 
between  such  attacks  as  these  the  patient  suffers  Httle 
or  not  at  all.  There  is  neither  pain  nor  tenderness 
over  the  liver  and  the  jaundice  grows  gradually  paler. 
Jaundice,  which  was  described  by  Courvoisier  as  the 
''cardinal  symptom"  of  common  duct  obstruction, 
never  disappears,  though  in  very  old-standing  cases 
the  patients  may  say  that  they  are  free  from  jaundice 
when  there  is  still  an  obvious  tinge  of  yellow  in  the 
conjunctivse  and  in  the  skin.  In  one  patient,  a  woman, 
who  had  suffered  from  these  ague-like  paroxysms  for 
nine  years,  the  skin  was  said  to  be  ''sallow"  normally, 
and  the  suggestion  that  she  was  jaundiced  to  a  slight 
degree  met  with  no  confirmation.  It  was  only  after 
the  removal  of  one  large  and  several  smaller  stones  from 
the  common  duct  that  the  patient  became  convinced, 
as  her  skin  gradually  whitened,  that  the  sallowness 
was  due  to  jaundice,  from  which  she  had  never  been 
free  through  all  the  nine  years.  Many  patients  noticed 
that  the  jaundice  varies  during  the  course  of  the  day, 
being  lighter  in  the  morning  and  becoming  deeper 
towards  night. 

The  temperature  angle  in  a  case  of  common  duct 
obstruction  by  a  stone  is  quite  characteristic.  With 
each  attack  of  pain  there  is  a  rapid  elevation  of  tempera- 
ture when  the  rigor  occurs.     As  the  rigor  passes  off  the 

148 


SURGERY  OF  THE  COMMON  BILE-DUCT. 


temperature  remains  until  the  next  seizure  of  pain 
occurs,  when  the  temperature  mounts  to  103°  or  104°, 
to  fall  again  at  once.  This  rapid  elevation  and  sudden 
fall  of  the  temperature  in  each  *' attack"  when  the 
temperature  is  normal  in  the  intervals  causes  the  chart 
of  a  case  of  this  kind  to  be  perfectly  characteristic. 
I  suggested  for  it  some  time  ago  a  name  which  seems 
quite  appropriate  and  which  has  been  since  widely 
adopted — the  name  '^steeple  chart." 

Courvoisier,  in  his  analysis  of  recorded  cases,  found 
fever  in  25  per  cent,  of  the  cases  of  occlusion  from  stone 
and  in  only  10  per  cent,  of  the  cases  of  occlusion  due  to 
other  causes.  The  former  estimate  seems  to  me  to  be 
considerably  below  the  truth.  If  a  case  of  common- 
duct  obstruction  be  observed  for  a  period  of  two  or  three 
weeks,  there  will,  ^dth  few  exceptions,  be  found  some 
abrupt  elevation  of  temperature  coinciding  with  the 
pain,  and  attacks  of  shivering  and  subsequent  sweating, 
not  perhaps  of  sufficient  gravity  to  be  considered  as 
rigors,  will  occur.  During  an  attack,  and  for  some 
hours  after,  there  may  be  a  slight  enlargement  of  the 
liver  and  the  liver  everywhere  is  tender  to  the  touch. 
In  chronic  obstruction  of  the  common  duct  the  liver 
is  always  enlarged  in  the  earlier  stages;  its  increase  in 
size  may  indeed  be  considerable.  The  liver  may  reach 
to  the  umbilicus  or  even  descend  beyond  it.     In  each 

149 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

attack,  when  a  rigor  and  an  elevation  of  temperature 
followed  by  a  deepening  of  the  jaundice  occur,  an  in- 
crease in  the  size  of  the  liver  may  be  observed,  and  the 
organ  on  handUng  is  found  to  be  tender.  In  the  latter 
stages  the  liver  decreases  slowly  in  size  and  at  the  last 
may  be  even  smaller  than  the  normal.  According  to 
Mongourt,  the  shrinkage  of  the  liver  is  the  most  im- 
portant sign  of  the  degeneration  of  the  hepatic  cells. 
The  condition  of  the  stools  and  of  the  urine  varies  from 
time  to  time.  As  a  rule,  some  bile  passes  always  into 
the  intestine,  so  that  the  motions  are  a  deep  buff  in 
colour.  After  an  attack  there  is  obvious  evidence, 
both  in  the  faeces  and  in  the  urine,  that  less  bile  is 
getting  access  to  the  duodenum.  The  variations  are, 
however,  much  more  readily  recognised  in  the  stools 
than  in  the  urine.  The  persistent  presence  of  urobilin 
in  the  urine  is  held  by  many  observers  to  indicate  the 
onset  and  the  continuance  of  a  process  damaging  to 
the  hepatic  cells.  In  many  cases  an  enlargement  of 
the  spleen  is  noticed,  more  especially  after  an  attack 
and  for  some  days  subsequently.  The  gastric  dis- 
turbances noticed  in  cases  of  gall-stone  impaction  vary 
within  very  wide  limits.  There  may  be  nothing  more 
than  a  sense  of  uneasiness  in  the  epigastrium  and  dis- 
tension after  food,  for  which  there  is  often  a  distaste,  or, 
on  the  other  hand,  there  may  be  severe  vomiting  during, 

150 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

and  subsequent  to,  the  attack  and  a  feeling  of  profound 
nausea.  Itching  of  the  skin  is  almost  constant,  as  in 
all  forms  of  jaundice,  and  a  crop  of  boils  may  at  times 
break  out. 

One  of  the  most  marked  and  characteristic  symptoms 
of  obstruction  of  the  common  duct  by  stone  is  loss  of 
weight.  A  loss  of  two,  three,  or  four  stones  is  not  in- 
frequently recorded.  The  loss  is  both  rapid  and  con- 
siderable, and  after  a  successful  operation  is  very 
speedily  regained.  This  loss  of  weight  was  ascribed 
by  Fenger  to  ''intermittent,  frequent,  ptomaine  in- 
toxication— that  is,  bile  absorption — as  well  as  to 
disturbed  digestion."  It  is  most  important  that  this 
symptom  should  be  recognised  as  a  frequent  and  strik- 
ing manifestation  of  stone  in  the  common  duct,  for  the 
haggard,  wasted,  often  emaciated,  appearance  of  the 
patient  may  strongly  suggest  a  diagnosis  of  malignant 
disease.  It  is  more  than  likely  that  some  measure  of 
responsibility  for  this  symptom  may  rest  with  the 
pancreas,  the  secretion  of  which  may  be  profoundly 
modified  both  in  quality  and  in  quantity  by  an  ex- 
tension of  the  inflammation  from  the  common  duct  to 
the  canal  of  Wirsung  into  the  substance  of  the  pancreas. 
Chronic  pancreatitis  is  by  no  means  an  uncommon 
event  in  longstanding  obstruction  of  the  common  duct, 
wherever  the  obstruction  may  be. 

151 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

The  characteristic  signs  and  symptoms  of  stone  in 
the  common  duct,  therefore,  are: 

Jaundice. — The  jaundice  is  persistent  but  variable. 
It  never  wholly  disappears,  though  in  the  interval 
between  the  attacks  of  pain  may  be  so  slight  as  to  be 
almost  unnoticeable.  The  colour  becomes  deeper  after 
each  attack  of  pain  and  gradually  fades  away  in  the 
intervals.  In  some  patients  a  variation  in  the  depth 
of  tinge  is  noticed  in  the  course  of  the  day.  When  the 
jaundice  deepens,  there  is  an  increase  in  the  amount  of 
bile  in  the  urine  and  a  diminution  in  the  amount  in  the 
stools.  The  jaundice  in  common-duct  obstruction  may 
be  said  to  "ebb  and  flow." 

Pain. — Pain  may  be  constant  and  slight,  but  is 
liable  to  characteristic  exacerbations.  In  the  attacks 
the  pain  comes  on  suddenly,  rapidly  attains  a  maximum, 
when  it  is  colicky  in  character,  and  then  perhaps  quite 
suddenly  it  disappears.  Pain  may  radiate  across  the 
epigastrium  and  be  associated  with  attacks,  so  called, 
of  "  indigestion. '^ 

Fever. — ^The  elevations  of  temperature  are  character- 
istic, and  give  rise  when  recorded  to  a  "steeple  chart." 
There  is  a  sudden  elevation  at  the  time  of  the  onset  of 
pain;  there  are  a  rigor,  shivering  followed  by  sweating, 
and  a  speedy  return  of  the  temperature  to  the  normal, 
where  it  remains  until  the  next  attack.     The  paroxysms 

152 


SURGERY  OF  THE  COMMON  BILE-DUCT. 


of  pain,  fever,  and  jaundice  are  ague-like  in  character 
and  may  occur  with  remarkable  regularity. 

During  and  after  an  attack  there  are  tenderness  and 
enlargement  of  the  liver  and  probably  also  of  the  spleen. 
Itching  of  the  skin  is  always  present,  and  at  times  is  the 
most  distressing  feature  in  the  case,  rendering  rest  and 
sleep  impossible.     The  cause  of  the  attacks  is  probably 
to  be  found  in  a  renewed  attempt  on  the  part  of  the 
duct  to  expel  the  stone.     From  the  dilated  portion  of 
the  duct  the  stone  is  made  to  enter  the  narrower  por- 
tion below,  and  a  spasmodic  muscular  contraction  is 
set  up.     In  this  way  fresh  damage  is  done  to  the  duct, 
tension  is  increased,  infection  occurs,  a  cholangitis  or 
an  increase  of  an  inflammatory  condition  already  in 
existence   takes   place,   and  the   mucosa   throughout 
the  ducts  swells  and  narrows  the  lumen.     The  ob- 
struction, in  fact,  becomes  for  the  time  mechanically 
complete,  and  partly  for  this  reason,  and  partly  because 
of  the  renewed  attack  of  cholangitis,   the  jaundice 

deepens. 

In  the  most  severe  forms  of  infection  suppuration 
may  arise  in  the  duct.  It  is  certain  that  infection  is 
present  in  all  cases  attended  by  the  symptoms  just 
enumerated;  it  is  equally  certain  that  the  infection 
rarely  gives  rise  to  suppuration.  When  a  stone  is 
removed  from  the  common  duct,  even  when  jaundice 

153 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

is  marked  and  long  enduring,  it  is  in  my  experience  very 
rare  to  find  pus  in  the  ducts,  however  severe  the  clinical 
manifestations  may  have  been.  Some  authors — Kehr 
and  others — talk  of  foetid  pus  as  being  not  uncommonly 
found  behind  a  stone  in  the  common  duct.  In 
my  experience  it  is  almost  unknown.  A  suppurative 
cholangitis,  therefore,  is  a  rare  complication  of  im- 
pacted stone.  It  is  also  a  most  serious — often,  indeed, 
a  lethal — one.  The  suppuration  may  extend  not  only 
along  the  whole  length  of  the  common  duct,  but  also 
may  involve  the  cystic  duct  and  the  gall-bladder  (giv- 
ing rise  to  empyema)  and  the  hepatic  ducts.  In  some 
cases  an  abscess  or  abscesses  may  develop  in  the  liver 
by  direct  extension  of  the  infection  along  the  ducts, 
giving  rise  to  the  condition  known  as  biliary  abscess. 
A  gall-stone  may  remain  in  the  common  duct  for 
years.  In  one  of  my  patients  the  symptoms  had  been 
present  for  nine  years,  and  a  case  of  seventeen  years' 
duration  is  recorded  by  Korte.  One  of  the  conse- 
quences of  so  long-enduring  an  inflammation  in  the  duct 
is  that  the  head  of  the  pancreas  may  be  involved  by 
infection  of  Wirsung's  duct  or,  perhaps,  by  direct  or 
by  lymphatic  infection.  Chronic  pancreatitis,  as  was 
pointed  out  by  Riedel,  is  a  not  infrequent  complica- 
tion of  gall-stones  impacted  in  the  common  duct.  Opie 
has  shown  that  in  all  probability  many  cases  of  acute 

154 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

pancreatitis  are  due  to  the  impaction  of  a  stone  of  small 
size  in  the  ampulla  of  Vater,  the  result  being  that  the 
common  duct  and  the  duct  of  Wirsung  are  converted 
into  a  single  channel;  retrojection  of  bile  along  the 
duct  of  the  pancreas  then  occurs.  In  such  a  case  the 
symptoms  come  on  with  marked  suddenness.  They 
are  epigastric  pain  and  tenderness,  followed  by  dis- 
tension, vomiting,  and  collapse.  The  diagnosis  most 
often  made  is  one  of  intestinal  obstruction.  In  acute 
pancreatitis  with  fat  necrosis  there  is  no  increased 
leucocytosis;  in  acute  infective  cholangitis  there  is  a 
marked  leucocytosis.  There  are  many  other  causes, 
in  addition  to  calculus,  which  set  up  inflammatory 
changes  in  the  duct,  but  a  consideration  of  these, 
though  of  great  interest  and  importance,  must  be 
omitted  here. 

3.  Stricture  of  the  Common  Duct. 

This  may  be  congenital  or  acquired;  the  former 
condition  would  seem  to  be  the  more  frequent. 

(a)  Congenital  stenosis  of  the  common  duct  is  a  part 
of  the  disease  which  has  been  described  as  ''congenital 
obliteration  of  the  bile-ducts."  It  is  probable  that,  as 
Rolleston  has  suggested,  the  disease  is  primarily  started 
during  foetal  life  ''by  poisons  derived  from  the  mother 
and  conveyed  to  the  liver  of  the  foetus,  and  that  a 

155 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

mixed  cirrhosis  and  cholangitis  are  set  up."  The  result 
on  the  ducts  is  that  an  obliterative  cicatricial  process 
is  started.  The  stenosis  is  perhaps  found  more  com- 
monly at  the  lower  end  of  the  common  duct  than  else- 
where. Above  the  narrowed  part  the  duct  may  dilate 
and  form  a  cyst.  In  one  case,  the  specimen  of  which 
is  in  the  Museum  of  Guy's  Hospital,  three  and  a  half 
pints  of  bile  were  aspirated  from  the  cyst,  and  Oxley^ 
records  a  case  of  a  cyst  containing  36  ounces  of  bile 
occurring  in  a  child  six  weeks  old. 

The  existence  of  this  congenital  obliteration  or 
stenosis  of  the  ducts  in  foetal  life  and  in  early  infancy  is 
now  well  recognised.  It  is  not  so  generally  known  that 
a  condition,  probably  the  same,  certainly  closely  allied 
to  it,  is  found  in  young  adults.  In  them  jaundice  may 
first  appear  at  any  time  between  the  ages  of  ten  and 
twenty-five;  the  jaundice  gradually  deepens,  there  is 
no  pain,  nor  are  there,  as  a  rule,  any  rigors  or  other 
evidences  of  infection.  A  tumour,  cystic  in  character, 
may  be  recognised  below  the  costal  margin  on  the  right 
side.  On  opening  the  abdomen  a  stricture  of  the  com- 
mon duct,  generally  near  its  lower  end,  has  been  found, 
and  cholecystenterostomy,  or  choledocho-enterostomy, 
or  choledochotomy  with  drainage  have  been  performed. 
An  admirable  history  of  such  a  case  is  given  by  Swain.® 
Other  cases  are  recorded  by  Ashby,'  by  Korte,^  by 

156 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

Konitzky/  by  Seyffert/*'  and  by  Rostowzew.^^  In 
none  of  these  cases  was  there  any  history  of  cholehthia- 
sis.  The  stenosis  came  on  insidiously  and  was  prob- 
ably the  result  of  a  continuation  into  adult  life  of  a 
process  begun  in  early  infancy  or  in  foetal  life.  There 
would  be  an  analogy  then  in  the  condition  found  in 
the  pylorus  described  as  '^  congenital,  hypertrophic 
stenosis,"  which  is  believed  to  have  a  definite  relation- 
ship with  a  similar  condition  which  first  attracts  at- 
tention in  young  adults.  Most  of  the  cases  proved 
fatal  after  operation.  A  successful  operation  for  the 
similar  condition  is  recorded  by  Treves. ^^  The  patient, 
aged  nineteen  years,  had  been  jaundiced  since  the  age 
of  three  years.  At  the  operation  the  lower  end  of  the 
common  bile-duct  was  found  to  be  obliterated  or 
absent.     Cholecystenterostomy  proved  successful. 

(6)  Acquired  Stenosis  of  the  Common  Duct. — Acquired 
stricture  of  the  common  duct  results,  as  a  rule,  from 
the  healing  of  an  ulcer  which  has  been  caused  by  the 
pressure  or  the  constant  fretting  of  a  stone.  In  other 
cases  the  cause  may  be  an  ulceration  due  to  typhoid 
fever,  or  possibly  to  syphilis.  A  stone  which  has  been 
long  delayed  in  the  duct  may  pass  onwards  into  the 
duodenum,  and  a  stricture  then  slowly  develops.  As 
a  rule,  a  stone  is  found  in  the  strictured  duct  above  the 
obstruction.     Hoffman,  Merbach,  Wyeth,  and  others 

157 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

have  described  a  similar  condition  in  the  hepatic  duct; 
in  the  cystic  duct  it  is  seen  quite  commonly.  Pye- 
Smith^^  has  described  a  case  of  cicatricial  contraction 
of  the  common  duct  in  a  woman  aged  twenty-six  years; 
a  small  stone  lay  immediately  above  the  stricture. 
Johnson^^  records  a  remarkable  case  of  stricture  of  the 
upper  part  of  the  common  duct  in  a  woman  aged  thirty- 
eight  years.  The  symptoms,  after  being  present  for 
over  a  year,  disappeared,  to  return  a  year  later  shortly 
before  her  death.  Phillips^^  records  a  case  of  ''carti- 
laginous'' stricture  in  the  common  duct.  In  neither 
of  these  cases  were  gall-stones  found.  Korte^^  records 
the  case  of  a  man,  forty  years  of  age,  who  had  suffered 
for  five  months  from  jaundice,  rigors,  and  remittent 
fever.  On  opening  the  abdomen  the  gall-bladder  was 
found  to  be  dilated  and  stones  were  present  in  the 
cystic  duct.  The  hepatic  and  common  ducts  were 
dilated.  The  common  duct  was  opened  and  found  to 
contain  a  stone  behind  a  very  narrow  stricture.  The 
stricture  was  excised  and  an  end-to-end  anastomosis 
was  made  between  the  cut  ends.  A  drainage-tube  was 
placed  in  the  hepatic  duct  and  cholecystenterostomy 
was  performed.  The  patient  died  on  the  twelfth  day 
from  haemorrhage  from  an  ulcer  on  the  lesser  curvature 
of  the  stomach;  a  large  vessel  was  found  eroded. 
Pennato^^  gives  notes  of  one  case  of  stenosis  of  the 

158 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

common  duct  near  its  termination,  due  to  fibrous  in- 
flammatory thickening.  There  was  an  enormous  dis- 
tension of  all  the  ducts  behind  the  obstruction. 

I  have  operated  upon  one  case  of  this  kind.  The 
patient  was  a  man,  aged  sixty-three  years,  who  had 
the  typical  symptoms  of  a  stone  in  the  common  duct, 
and  who  had  suffered  from  his  disease  for  nearly  four 
years.  I  found  the  upper  part  of  the  common  duct 
greatly  dilated,  at  least  13^  inches  in  diameter.  In  the 
dilated  portion  a  small  stone  and  much  black  sand  were 
found.  The  common  duct  at  the  junction  of  its  first 
and  second  portions  rapidly  narrowed  like  a  wine-glass 
to  its  stem.  I  performed  a  plastic  operation  upon  the 
duct  and  drained  the  hepatic  duct.  For  nine  weeks 
bile  was  discharged  from  a  fistula,  but  at  the  end  of  that 
time  the  wound  became  dry  and  the  patient  has  since 
(for  over  nine  months)  been  perfectly  well. 

A  cicatricial  contraction  in  a  duodenal  ulcer  may 
cause  a  narrowing  of  the  duct.  I  have  met  with  only 
one  such  case.  The  scar  in  the  duodenum  felt  like  a 
stone  fixed  in  the  ampulla.  I  opened  the  duodenum 
to  remove  the  stone,  when  a  hard  cicatricial  nodule  was 
found.  There  was  no  suspicion  as  to  its  malignancy. 
I  therefore  united  the  wound  in  the  bowel  to  the  gall- 
bladder (cholecystenterostomy),  affording  a  complete 
relief  to  the  symptoms.     The  patient   remains  well 

159 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

four  and  a  half  years  after  the  operation.  A  case  of 
excision  of  a  simple  stricture  of  the  common  duct  is 
recorded  by  Kehr.  In  one  case,  in  addition  to  that 
mentioned  above,  Korte  excised  a  stricture  of  the 
common  duct  which  he  supposed  was  cicatricial.  On 
microscopic  examination  it  was  found  that  the  condi- 
tion was  carcinomatous.  There  can  be  no  doubt  that 
a  stricture  which,  to  the  naked  eye,  appears  merely 
fibrous  may  be  undoubtedly  carcinomatous;  cases  in 
support  of  this  statement  are  related  by  Krokiewicz, 
Korte,  and  others. 

4.  Carcinoma  of  the  Common  Bile-duct. 

Cancer  of  the  bile-ducts  is  rare;  the  common  duct  is 
affected  far  more  frequently  than  the  hepatic  or  cystic 
ducts.  It  is  not  improbable  that  the  disease  is  more 
common  than  the  records  seem  to  show,  for  the  re- 
semblance in  certain  cases  to  a  simple  fibroid  thickening 
of  the  duct  is  very  close.  It  is  well  known  that  in  a 
very  large  proportion  of  cases  of  carcinoma  of  the 
gall-bladder  the  condition  is  associated  with,  and  its 
onset  determined  by,  gall-stones.  The  dependence  of 
cancer  of  the  common  bile-duct  upon  the  prolonged 
irritation  of  stones  is  far  less  clear.  In  40  cases  col- 
lected by  Devic  and  Gallavardin^^  gall-stones  were 
found  nine  times — three  times  in  the  duct  and  six 

160 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

times  in  the  gall-bladder.  RoUeston  in  80  cases  found 
that  gall-stones  were  referred  to  in  62  cases;  in  23  it 
was  noted  that  they  were  present,  in  39  that  they  were 
absent.  The  growth  may  affect  any  portion  of  the 
duct,  but  though  there  is  no  point  of  predilection,  the 
ends  of  the  duct  seem  to  be  more  commonly  attacked 
than  the  central  portion.  In  57  cases  mentioned  by 
Rolleston  the  upper  end,  the  junction  of  hepatic,  cystic, 
and  common  ducts,  was  affected  25  times,  the  middle 
part  11,  and  the  lower  end  21  times. 

The  growth  appears  in  two  characteristic  forms, 
which  may  be  described  as  the  projecting  and  the 
infiltrating.  In  the  first  it  is  small  in  size  and  projects 
as  a  firm,  white  nodule  into  the  lumen  of  the  duct. 
When  during  an  operation  the  duct  is  gripped  between 
the  fingers,  the  impression  that  the  lump  is  a  calculus 
is  very  strong.  The  projecting  mass  may  undergo 
ulceration  and  bleeding  be  caused  thereby.  In  the 
second  form  the  groTvi^h  infiltrates  the  duct,  converting 
it  for  a  part,  or  for  the  whole,  of  its  length  into  a  rigid, 
thickened  tube.  The  stricture  thus  formed,  especially 
when  localised,  may  readily  be  mistaken  for  a  cicatricial 
mass,  the  result  of  the  healing  of  an  ulcer.  The  in- 
filtrating form  is  seen  more  commonly  at  the  upper 
end  of  the  duct,  the  growth  spreading  upwards  into 
the  cystic  and  hepatic  ducts.  The  groTvi:h,  as  a  rule,  is 
11  161 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

small,  but  Brenner  records  an  instance  in  which  the 
tumour  formed  was  as  large  as  a  hen's  egg,  and  Rolles- 
ton  one  of  the  size  of  an  orange.  The  growth  does  not 
spread  easily  to  surrounding  parts,  a  few  glands  may- 
be enlarged,  and  deposits  at  times  are  seen  in  the  liver, 
but  metastases  rarely  occur.  In  a  very  few  cases  the 
growth  is  palpable  on  examination  of  the  abdomen. 
Behind  the  growth,  of  either  form,  all  the  ducts  are 
dilated;  this  is  a  constant  feature.  The  gall-bladder  is 
dilated  also.  Devic  and  Gallavardin  in  18  cases  of 
growth  in  the  common  duct  found  the  gall-bladder  dis- 
tended in  17,  and  in  14  cases  of  cancer  at  the  conflu- 
ence of  the  three  ducts  7  times.  In  one-half  the  cases 
the  gall-bladder  is  easily  palpable. 

The  growth  begins  insidiously  and  increases  steadily. 
The  symptom  to  which  it  first  gives  rise  is  jaundice, 
which  begins  almost  imperceptibly,  deepens  by  the 
slowest  degrees,  and  never  recedes.  As  the  colour 
deepens  less  bile  is  noticed  in  the  stools  and  bile  appears 
in  the  urine.  There  is  progressive,  unceasing  emacia- 
tion, week  by  week  strength  is  lost,  and  the  body-weight 
decreases.  In  all  recorded  cases  the  very  striking 
cachectic  appearance  of  the  patient  is  mentioned. 
Ascites  may  rarely  appear  from  pressure  upon,  or  in- 
volvement of,  the  portal  vein.  Splenic  enlargement  is 
infrequent.     In  some  cases  the  conditions  may  be  com- 

162 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

plicated  by  the  presence  of  a  stone  in  the  duct.  The 
symptoms  then  are  anomalous.  In  only  one  recorded 
case,  that  of  Stokes,  has  there  been  intermittent  fever. 
Death  may  be  due  to  gradual  exhaustion,  to  haemor- 
rhage, to  rupture  of  the  gall-bladder,  or  to  the  onset  of 
an  acute  infection  in  the  duct. 

Treatment. — Carcinoma  of  the  common  duct  is 
generally  unsuspected.  Only  one  case,  so  far  as  I  am 
aware,  has  been  positively  diagnosed.  The  treatment 
that  is  necessary  will  depend  upon  the  position  and 
extent  of  the  growth.  If  the  gro^iih  be  limited,  of  the 
''projecting"  type,  the  part  of  the  duct  in  which  it 
lies  should  be  removed.  A  cylinder,  one  inch  or  more, 
must  be  cut  away,  and  if  enlarged  glands  are  found, 
they  also  must  be  removed.  After  the  removal  of  the 
growth  an  end-to-end  approximation  may  be  made,  if 
need  be,  when  the  duodenum  has  been  ''mobilised" 
after  the  method  of  Kocher.  Drainage  should  be 
provided  for,  the  circular  suture  being  incomplete  at 
one  part  where  a  tube  is  introduced.  If  end-to-end 
anastomosis  cannot  be  performed,  the  distal  end  of 
the  severed  duct  may  be  closed  by  ligature  and  the 
proximal  end  anastomosed  with  the  duodenum.  Or 
both  ends  may  be  closed  and  cholecystenterostomy 
performed. 

If  the  growth  be  extensive,  of  the  "infiltrating"  type, 

163 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

resection  of  the  duct  may  still  be  possible,  but  suture 
of  the  divided  ends,  then  so  far  separated,  is  out  of  the 
question.  Ligature  of  the  ends  and  cholecystenteros- 
tomy  may  be  performed.  If  the  growth  is  irremove- 
able,  a  palliative  operation — cholecystenterostomy — 
may  give  relief  to  the  most  urgent  and  most  troublesome 
symptom — ^jaundice. 

Dr.  W.  J.  Mayo^^  makes  some  very  practical  remarks 
upon  cases  of  operative  defect  of  the  common  bile-duct. 
He  records  two  cases  in  which  growths  were  removed 
from  the  common  duct — in  one  end-to-end  anastomo- 
sis was  performed  and  in  the  other  choledocho-duo- 
denostomy — and  two  cases  in  which  a  part  of  the  duct 
was  removed  together  with  the  cystic  duct  and  the 
gall-bladder.  Brenner  reports^*'  two  cases  operated 
upon  by  Jordan,  of  Heidelberg.  In  both  the  cancer 
was  unrecognised  at  the  operation;  both  patients  died 
and  the  condition  of  cancer  of  the  duct  was  discovered 
post  mortem.  Kehr  records  one  case  of  choledochec- 
tomy  for  cancer.  I  have  only  once  had  to  deal  with 
cancer  of  the  common  duct  by  operation.  The  growth 
involved  the  common  hepatic,  cystic,  and  common 
bile-ducts.  The  growth  with  the  gall-bladder  was 
removed  and  the  distal  end  of  the  common  duct, 
rendered  mobile  by  freeing  the  duodenum,  was  sutured 


164 


SURGERY  OF  THE  CO^^IMOX  BILE-DUCT. 


to  the  proximal  cut  end  of  the  hepatic  duct  and  drain- 
age was  instituted. 

5.  Pressure  upon  the  Duct  from  Without. 
There  are  numerous  conditions  which  cause  blocking 
of  the  conmaon  duct  by  compressing  it  from  the  outside 
or  by   causing  kinking.     These   conditions   are:     (a) 
chronic  inflammatory  enlargement  of  the  head  of  the 
pancreas;    (5)  tumours  of  the  pancreas  (cysts,  carci- 
noma, calculus) ;   (c)  ulcer  or  carcinoma  of  the  stomach 
or  duodenum;  (d)  peritonitis  which  results  in  adhesions 
around  the  duct;    (e)  enlargements  of  the .  lymphatic 
glands  along  the  duct  due  to  tubercle,  lymphadenoma, 
or  carcinoma;    (/)  stone  in  the  cystic  duct,  causing 
compression  of  the  duct;    {g)  tumours  growing  from 
the  kidney,  adrenals,  retroperitoneal  tissues,  or  else- 
where;   (/i)  aneurysms  of  the  larger  vessels,  aorta,  su- 
perior mesenteric,  hepatic;    and  (i)   hepatoptosis,  or 
nephroptosis  causing  kinking  of  the  duct.     The  mere 
enumeration  of  these  conditions  is  sufficient  to  show 
that  any  detailed  consideration  of  them  would  carry 
one  far  beyond  the  scope  of  this  paper.     Most  of  the 
conditions  cause  an  interference  with  the  common  duct 
only  as  a  matter  of  secondary  significance,  and  they 
do  not  call,  therefore,  for  any  surgical  interference  Tsdth 
the  duct  itself. 

165 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

Operations  upon  the  Common  Duct. 

The  operations  practised  upon  the  common  duct  are : 
(1)  choledochotomy;  (2)  choledochostomy;  (3)  chole- 
dochectomy;  (4)  choledochoplasty;  and  (5)  choledocho- 
enterostomy.  In  all  operations  upon  the  common 
duct  it  will  be  found  of  great  advantage  to  place  a 
sandbag  under  the  patient's  back,  behind  the  liver, 
to  make  a  free  opening  into  the  abdomen  by  Bevan's 
incision,  or  by  Mayo  Robson's  incision  (a  curtailed 
Bevan's  incision),  and,  if  possible,  to  lift  up  the  lower 
edge  of  the  right  lobe  of  the  liver,  to  turn  it  upwards 
and  outwards  through  the  incision,  and  in  this  way  to 
put  the  ducts  on  the  stretch  and  to  bring  them  near 
to  the  surface.  As  soon  as  the  abdomen  has  been 
opened  and  the  exact  condition  of  things  discovered, 
gauze  swabs  must  be  packed  in  the  wound  to  cover 
and  to  protect  all  the  parts  in  the  immediate  neigh- 
bourhood of  the  operation  area.  A  large  swab  is 
passed  backwards  into  the  upper  part  of  the  kidney 
pouch,  a  second  downwards  towards  the  pelvis  on  to 
the  transverse  colon,  and  a  third  inwards  to  the  middle 
line  over  the  gastro-hepatic  omentum.  Over  these 
large  swabs  smaller  ones  are  placed  which  are  changed 
from  time  to  time  as  they  are  soiled.  The  larger  ones 
remain  throughout  the  operation. 

166 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

1.  Choledochotomy. — The    common     duct    may    be 
opened  in  its  first,  second,  or  third  portion. 

(a)  In  its  first  portion  the  duct  is  exposed  by  freeing 
the  adhesions  around  it  and  rotating  the  liver  in  the 
manner  already  described.  The  stone  is  then  located 
and  is  gripped  between  the  finger  and  thumb  of  the  left 
hand.  With  the  stone  so  held  a  suture  is  introduced 
into  the  duct  on  each  side  of  it,  the  needle  being  passed 
into  the  lumen  of  the  duct  and  picking  up  the  duct 
walls  at  two  or  three  points.  The  stone  acts  the  part 
of  a  '^ darning  ball"  (the  ball  thrust  into  a  stocking  that 
is  being  darned),  making  the  introduction  of  the  needle 
easy.  The  two  sutures  are  of  catgut  and  are  left  long. 
The  duct  is  held  up  by  traction  upon  them  and  incised 
on  to  the  stone.  The  edges  of  the  duct  may  be  seized 
then  with  long  fine  vulsellum  forceps.  The  stone  is 
extracted  and  any  other  stones  that  are  easily  felt  are 
taken  away  also.  The  finger  is  then  passed  into  the 
duct,  an  additional  glove-finger  being  put  on.  The 
finger  should  be  passed  upwards  to  the  bifurcation  of 
the  hepatic  duct  and  downwards  to  the  ampulla.  It 
is  with  the  finger  alone  that  calculi  can  be  detected; 
a  spoon  or  a  probe  is  quite  useless.  When  all  the  stones 
are  abstracted  pieces  of  gauze  are  passed  into  the  duct 
and  will  bring  away  with  them  some  fine  sand.  If 
there  is  much  thick,  muddy  sand  in  the  duct  it  may  be 

167 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

necessary  to  wash  it  out  with  saHne  solution  introduced 
by  a  syringe  which  gives  good  pressure.  During  all 
these  manipulations  care  must  be  taken  to  prevent 
the  soiling  of  parts  by  the  constant  packing  with,  and 
changing  of,  the  swabs.  When  the  duct  is  clear,  it 
may  be  closed  with  a  suture  or  may  be  drained.  If 
the  gall-bladder  is  healthy  and  the  cystic  duct  patent, 
the  duct  should  be  closed  by  a  continuous  suture. 
The  removal  of  the  gall-bladder  if  the  cystic  duct  is 
patent  is,  in  my  opinion,  most  inadvisable  in  cases  of 
stone  in  the  common  duct.  The  two  stitches,  which 
have  been  already  introduced  as  retractors,  are  tied, 
the  upper  ends  and  the  lower  ends  of  one  to  the  corre- 
sponding ends  of  the  other;  after  tightening  the  ends 
are  left  long  till  a  continuous  suture  is  passed  over 
them.  The  gall-bladder  is  then  opened  and  drained. 
In  many  cases  of  common  duct  stone  the  gall-bladder 
is  small,  shrunken,  and  buried  in  adhesions.  It  is 
useless,  therefore,  for  purposes  of  drainage.  In  such 
circumstances  a  tube  must  be  introduced  into  the 
common  duct  and  passed  upwards  to  the  hepatic  duct. 
When  so  introduced  it  is  fixed  by  a  single  catgut  stitch 
and  the  wound  in  the  duct  is  closed  up  to  the  tube  by 
one  or  two  interrupted  sutures  of  catgut;  the  gall- 
bladder, if  the  patient^s  condition  permits,  should  then 
be  removed.     In  many  cases  I  have  removed  the  gall- 

168 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

bladder  first  and  then  have  sht  up  the  stump  of  the 
cystic  duct  into  the  common  duct  at  its  origin,  where 
a  tube  is  introduced  after  the  removal  of  the  stones. 
In  either  case,  whether  the  duct  is  directly  drained  or 
not,  a  split  rubber  tube  is  passed  down  by  the  side  of 
the  duct  and  beyond  it  into  the  upper  part  of  the 
kidney  pouch. 

The  operation  of  choledochotomy  in  a  simple  case 
where  the  gall-bladder,  though  containing  stones,  is 
reasonably  healthy  and  adhesions  are  few  and  easily 
separable,  offers  no  difficulties  whatever  and  can  be 
completed  within  half  an  hour.  But  in  many  cases 
adhesions  are  numerous,  of  old  standing,  and  therefore 
tough,  and  in  some  cases  fistulous  tracks  may  exist 
between  the  gall-bladder  and  the  duodenum  or  the 
colon.  The  conditions  in  the  gall-bladder  may  have 
undergone  what  Mr.  J.  Rutherford  Morison  aptly  calls 
the  "natural  cure,"  the  stones  may  be  securely  iso- 
lated in  the  gall-bladder  or  embedded  in  the  liver,  and 
the  cystic  duct  may  be  closed.  A  patient  with  such  a 
condition  has  suffered  perhaps  for  a  great  many  years. 
She  is  therefore  old  and  not  improbably  is  feeble  in 
health.  If  a  stone  in  the  common  duct  be  causing 
urgent  symptoms,  its  removal  alone  may  be  as  much 
as  the  patient  can  bear.  The  "cured"  condition  of 
things  in  the  gall-bladder  must  then  be  ignored,  for  to 

169 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

deal  with  them  would  involve  the  performance  of 
cholecystectomy,  partial  hepatectomy,  or  the  closing 
of  fistulous  openings  in  the  bowel.  If  the  stone  in  the 
common  duct  is  removed  and  the  duct  cleared  of  sand 
or  other  stones  and  drained,  the  patient,  after  recovery 
from  the  operation,  suffers  no  further  troubles. 

It  is  for  such  cases — for  cases  where,  owing  to  the 
patient's  age  or  general  condition  or  to  the  local  con- 
ditions present,  nothing  more  than  the  common  duct 
operation  is  possible — that  I  have  adopted  the  method 
I  have  elsewhere  described  as  ''rotation  of  the  common 
duct."  By  this  method  the  adhesions  are  ignored  and 
the  stone  is  yet  easily  removed.  As  soon  as  the  con- 
dition of  things  is  seen  the  left  hand  of  the  surgeon  is 
passed  transversely  inwards  in  front  of  the  pylorus  and 
above  the  stomach,  along  the  gastro-hepatic  omentum. 
When  the  hand  is  well  placed,  the  thumb  is  passed 
downwards  to  the  common  duct,  so  that  the  gall- 
bladder remnant  buried  in  adhesions  then  lies  in  the 
cleft  between  the  thumb  and  first  finger  and  the  tip 
of  the  thumb  is  against  the  stone.  The  hand  is  now 
rotated,  the  fingers  are  flexed,  and  the  hand  and  wrists 
are  bent  over  to  the  patient's  left.  The  stone  in  the 
duct  is  thus  brought  well  up  into  the  wound  and  is 
easily  seen.  Behind  and  around  it  swabs  are  placed, 
a  stitch,  or  two  stitches,  introduced,  the  duct  is  incised, 

170 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

the  stone  is  removed,  a  tube  is  placed  in,  fixed  with  a 
stitch,  and  the  operation  is  complete.  Rotation  of  the 
duct  avoids  the  necessity  of  the  free  separation  of 
adhesions  and  converts  what  might  be  an  exceedingly- 
formidable  and  prolonged  operation  into  a  simple, 
speedy,  and  therefore  far  safer  one. 

There  are  cases  in  which  when  the  stone  or  stones 
have  been  removed  from  the  duct  an  immoveable  one 
is  felt  in  the  ampulla.  This  must  then  be  removed 
through  the  duodenum  in  the  manner  to  be  mentioned 
presently.  The  wound  in  the  duct  may  well  be  left 
open  until  the  ampulla  is  incised,  and  a  piece  of  gauze 
passed  from  the  one  opening  to  the  other  will  bring 
away  with  it  much  fine  sand. 

(5)  In  its  Second  Portion  {Retro-duodenal  Choledochot- 
omy) . — The  retro-duodenal  portion  of  the  duct  may  be 
reached  from  behind  by  a  procedure  similar  to  that 
employed  by  Kocher  in  the  "mobilising  of  the  duode- 
num" as  a  preliminary  to  the  performance  of  gastro- 
duodenostomy.  This  method  was  suggested  at  the 
German  Surgical  Congress  in  1898  by  Haasler.  It  had 
been  found  necessary  three  times  in  18  operations  for 
stone  in  the  common  duct.  Oscar  Bloch,  of  Copen- 
hagen, has  described  a  similar  operation  to  this.  In 
the  very  great  majority  of  cases  a  stone  which  appears 
to  be  fixed  in  this  portion  of  the  duct  can  be  moved 

171 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

upwards    into    the    first    portion.     The    operation    is 
therefore  very  rarely  necessary. 

(c)  In  its  Third  Portion  {Trans-duodenal  Choledochot- 
omy). — When  the  duodenum  is  opened,  the  calculus 
may  be  found  in  the  lower  part  of  the  duct  or  in  the  am- 
pulla. If  in  the  latter,  the  ampulla  is  incised  and  the 
stone  is  extracted  (McBurney's  operation);  if  in  the 
former,  the  posterior  wall  of  the  duodenum  over  the 
duct  is  incised  (Kocher's  operation).  The  earlier  steps 
in  both  methods  are  the  same.  The  duodenum  is 
exposed,  and  if  deeply  placed  or  not  easily  accessible, 
it  may  be  freed  by  a  vertical  incision  in  the  peritoneum 
to  its  right  side.  The  stone  is  fixed  by  grasping  it 
between  the  thumb  and  the  fingers  of  the  left  hand. 
The  duodenum  is  then  opened  by  a  vertical  incision 
about  one  inch  or  a  little  more  in  length.  The  edges 
of  this  incision  are  grasped  with  fine  vulsella  and  held 
apart.  The  greatest  care  is  taken  to  prevent  any 
leakage  from  the  duodenum.  The  fluid  therein  is 
mopped  up  at  once  by  swabs  which  are  instantly  dis- 
carded. As  soon  as  the  duodenum  is  well  opened  the 
stone  is  readily  felt  or,  if  in  the  ampulla,  may  be  seen. 
If  in  the  ampulla,  the  edges  of  the  opening  are  enlarged 
and  the  stone  is  taken  away.  If  in  the  duct,  the  walls 
of  the  duodenum  are  incised  over  the  stone  or  the  duct 
is  slit  up  on  a  director  passed  into  the  ampullary  orifice 

172 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

and  the  stone  dislodged.  In  both  cases  a  further  search 
for  other  stones  is  necessary,  the  finger  being  passed 
upwards  into  the  duct,  which  readily  admits  it.  If 
the  duct  has  had  to  be  divided  freely,  the  incision  may 
be  closed  by  suture  or  the  opening  left  patent,  the 
operation  being  then  known  as  choledocho-duodenos- 
tomy. 

2.  Choledochostomy  is  performed  when  the  common 
duct  is  dilated  so  as  to  form  a  cyst.  In  most  cases  the 
swelling  has  been  mistaken  for  the  gall-bladder.  (For 
records  of  cases  see  '' Gallstones  and  Their  Surgical 
Treatment,"  second  edition,  pp.  418  et  seq.) 

3.  Choledochectomy  is  performed  in  cases  of  malignant 
disease  or  when  in  the  removal  of  the  stone  the  duct  has 
been  torn  across.  Cases  are  recorded  by  Doyen,  Mayo, 
and  myself.  The  ends  of  the  duct  may  be  approxi- 
mated, or  the  distal  end  closed,  and  the  proximal  im- 
planted into  the  duodenum,  or  both  ends  may  be  closed 
and  cholecystenterostomy  performed,  or  the  defect  in 
the  duct  may  be  repaired  by  a  flap  taken  from  the 
stomach. 

4.  Choledochoplasty. — I  have  once  performed  a  plastic 
operation  upon  the  common  duct  in  a  case  of  simple 
stricture  of  the  duct,  slitting  the  duct  up  longitudinally 
and  stitching  it  transversely;  an  opening  was  left  for 
drainage.     The  result  has  been  very  good.     Kehr  has 

173 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

repaired  a  defect  in  the  common  duct  by  turning  a 
seromuscular  flap  upwards  from  the  stomach. 

5.  Choledocho-enter ostomy  is  performed  when  there 
is  an  impermeable  stricture  of  the  common  duct  which 
is  greatly  dilated  behind  the  obstruction.  A  number 
of  cases  have  been  recorded  since  Riedel  first  performed 
the  operation  in  1888.  Kocher's  method  of  choledocho- 
duodenostomy  between  the  third  portion  of  the  duct 
and  the  second  portion  of  the  duodenum  has  already 
been  mentioned. 

In  cases  where  the  common  duct  is  drained  it  is 
desirable  to  keep  in  the  tubes  for  at  least  a  fortnight. 
An  examination  of  a  post-mortem  specimen  of  common 
duct  obstruction  by  stone  will  show  the  evidences  of 
cholangitis  which  may  extend  upwards  to  the  minute 
ducts  in  the  liver.  To  give  time  for  these  ducts  to  rid 
themselves  of  infection  is  important.  It  is  my  custom 
in  all  these  cases  to  administer  urotropine  to  the  patient 
immediately  after  the  operation  and  for  a  few  days 
before  it  if  opportunity  permits.  In  a  case  which  I 
published  in  ''The  Lancet  "^^  the  excretion  of  urotropine 
in  the  bile  was  proved  by  the  rapid  disappearance  of 
typhoid  organisms  which  were  present  therein  when 
this  drug  was  administered  in  ten-grain  doses  thrice 
daily. 


174 


SURGERY  OF  THE  COMMON  BILE-DUCT. 

REFERENCES. 

1.  Memoires  de  la  Society  de  Biologie,  vol.  xxxi. 

2.  New  York  Medical  Journal,  1877,  p.  531. 

3.  Bristowe:    Transactions   of   the  Pathological  Society   of 
London,  London,  1858,  vol.  ix,  p.  285. 

4.  Morris:  New  York  Medical  Record,  Jan.  1,  1887,  p.  22. 

5.  The  Lancet,  Dec.  8,  1883,  p.  988. 

6.  The  Lancet,  March  23,  1895,  p.  743. 

7.  Medical  Chronicle,  October,  1898,  p.  28. 

8.  Beitrage  zur  Chirurgie  der  Gallenwege,  p.  227. 

9.  Inaugural-Dissertation,  Marburg,  1888. 

10.  Inaugural-Dissertation,  Greifswald,  1888. 

11.  Deutsche  medicinische  Wochenschrift,  1902,  p.  739. 

12.  Practitioner,  January,  1899,  p.  18. 

13.  Transactions  of  the  Pathological  Society,  vol.  xxiv,  p.  250. 

14.  Brit.  Med.  Jour.,  1880,  vol.  ii,  p.  200. 

15.  The  Lancet,  Nov.  5,  1887,  p.  916. 

16.  Beitrage  zur  Chirurgie  der  Gallenwege,  p.  341. 

17.  La  Clinica  Moderna  Italiana,  1901,  No.  6. 

18.  Revue  de  Medecine,  July,  1901,  p.  575. 

19.  Annals  of  Surgery,  July,  1905,  p.  90. 

20.  Virchow's  Archiv,  1899,  vol.  clviii,  p.  253. 

21.  The  Lancet,  June  6,  1903,  p.  1586. 


175 


The  Operative  Treatment  of  Obstruc- 
tive Jaundice  and  the  Proper 
Selection  of  Cases.* 

Introduction  to  a  Discussion  in  the  Section  of  Surgery  at 

THE  Annual  Meeting  of  the  British  Medicaid 

Association,  Belfast,  July,  1909. 

In  the  proper  selection  of  cases  of  obstructive  jaun- 
dice for  surgical  treatment,  the  surgeon  may  find  his 
capacity  for  accurate  diagnosis  taxed  to  the  very  ut- 
most. It  is  true  that  there  are  certain  types  of  case 
easily  to  be  recognised,  about  which  hardly  any  doubt 
or  difference  of  opinion  can  be  entertained,  but  it  is 
also  true  that  there  are  elusive  cases  in  which  no  refine- 
ment of  clinical  acumen,  nor  any  subtile  investigation 
of  the  chemical  changes  occurring  in  the  bod}^,  will 
enable  a  confident  diagnosis  to  be  made.  Such  cases 
cannot  be  too  closely  examined,  nor  too  strictly  de- 
bated, and  a  discussion  such  as  this  will  doubtless  help 
to  throw  light  upon  a  difficult,  interesting,  and  im- 
portant problem. 

*  Reprinted  from  the  British  Medical  Journal,  October  2, 
1909. 

12  177 


OBSTRUCTIVE  JAUNDICE. 


Diagnosis. 

In  endeavouring  to  arrive  at  an  accurate  diagnosis 
in  a  case  of  obstructive  jaundice,  and  therefore  at  a 
proper  selection  of  those  cases  for  which  surgical  treat- 
ment is  necessary,  three  separate  branches  of  enquiry 
must  be  followed.  These  are  concerned  with:  (1)  The 
clinical  history;  (2)  the  physical  signs;  (3)  the  chem- 
ical investigation  of  the  urine  and  fseces. 

1.  The  Clinical  History. — I  am  inclined  to  think  that 
a  close  enquiry  into  the  most  intimate  details  of  the 
clinical  history  will  afford  the  most  substantial  help. 
The  exact  details  of  the  mode  of  onset  of  the  jaundice 
must  be  ascertained.  In  some  cases  the  onset  is  most 
insidious;  the  slight  tinge  of  sallowness  in  the  skin  is 
not  at  first  recognised  as  being  due  to  a  faint  jaundice, 
and  the  earliest  discovery  of  the  patient's  condition  is 
made,  not  by  himself  but  by  another,  who  comments 
upon  his  altered  appearance.  It  is  then  noticed  that 
by  slow  degrees  the  jaundice  deepens.  There  is 
neither  haste  nor  pause  in  the  process,  and  to  the 
patient,  and  to  those  who  see  him  constantly,  the 
change  may  seem  imperceptible  from  day  to  day.  The 
progression  is  never  checked,  nor  is  there  at  any  time  a 
temporary  lessening  of  the  colour.  The  change  is  slow, 
and  is  always  from  a  lighter  to  a  deeper  tinge.     Finally 

178 


OBSTRUCTIVE  JAUNDICE. 


a  jaundice  which  the  older  physicians  described  as 
''black"  may  be  seen;  the  colour  is  intensely  deep  and 
is  dark  green,  rather  than  yellow  or  ''black."  The 
deep  green  tinge  of  the  skin,  together  with  the  amber 
colour  of  the  conjunctivae,  makes  the  appearance  of  the 
shrunken  features  of  the  patient  very  striking.  In  a 
patient  whose  jaundice  has  so  progressed,  the  con- 
stitutional symptoms  are  significant.  A  period  of 
general  weakness,  ill  health,  and  emaciation  may  have 
preceded,  and  will  certainly  have  accompanied,  the 
jaundice.  There  is  rarely  any  pain,  usually  indeed 
the  patient  denies  the  experience  of  any  discomfort. 
He  complains  chiefly  of  a  general  languor,  increasing 
feebleness  and  loss  of  flesh,  distaste  for  food;  and  as  the 
bodily  health  and  vigour  decrease,  so  the  jaundice 
deepens. 

In  another  and  very  dissimilar  class  of  cases  the 
jaundice  will  appear  abruptly;  and  is  then  preceded, 
with  the  rarest  exceptions,  by  an  acute,  often  agonising, 
attack  of  pain.  Within  a  few  hours  of  the  cessation  of 
the  agony,  and  before  the  stiffness  and  soreness  which 
it  leaves  behind  have  passed  away,  the  skin  may  be 
everywhere  tinged  ^dth  yellow,  the  urine  is  dark,  and 
in  a  day  or  two  the  motions  are  pale  and  clay-coloured. 
The  jaundice  rapidly  deepens,  and  may  then  gradually 
subside,  and  in  a  few  days  may  pass  completely  away. 

179 


OBSTRUCTIVE  JAUNDICE. 


Or  it  may  be  otherwise:  the  jaundice  may  deepen  at 
first  rapidly,  and  then  may  seem  to  attain  its  maximum, 
and  remain  stationary  for  a  period  that  varies  from  a 
few  days  to  a  few  months.  At  the  end  of  this  period 
something  occurs — it  may  be  a  rigor,  or  a  repetition 
of  an  attack  of  pain  of  the  same  character  as  the  origi- 
nal seizure,  or  both  may  occur  together.  Soon  it  is 
clear  that  the  jaundice  is  perceptibly  deeper,  but  within 
a  few  days  it  begins  to  lessen,  and  may  seem  almost 
to  clear  away.  But  soon  another  attack  of  pain 
occurs,  often  accompanied  or  preceded  by  a  rigor  or  a 
sensation  of  chill,  the  temperature  rises  rapidly,  and 
presently  the  jaundice  begins  to  deepen.  This  se- 
quence of  events  is  repeated  sometimes  with  the  most 
exact  regularity,  but  usually  with  apparent  caprice. 
The  jaundice  may  at  last  become  very  slight  indeed, 
and  I  have  known  it  to  be  so  constant  and  sustained  a 
feature  of  the  case  that  the  recollection  of  the  patient, 
and  of  the  relatives,  of  the  original  natural  colour  of 
the  skin  has  long  been  forgotten.  When,  however, 
an  operation  has  removed  the  obstructive  causes  of 
the  jaundice  it  is  seen  that  what  has  been  so  long  called 
sallowness  is  really  a  discolouration  of  the  skin  by 
bile.  In  such  a  case  the  orderly  repetition  of  the  rigor, 
with  the  accompanying  abrupt  elevation  of  the  tem- 
perature, may  lead  to  a  diagnosis  of  malarial  fever. 

180 


OBSTRUCTIVE  JAUNDICE. 


The  foregoing  represent  the  two  chief  types  of  ob- 
structive jaundice,  the  one  beginning  insidiously  with- 
out pain,  and  going  on  unchecked  to  the  deepest 
tinge — the  ''black  jaundice"  of  the  older  writers — the 
other  beginning  abruptly,  and  then  following  upon  an 
acute  and  agonising  attack  of  pain,  deepening  for  a 
time,  but  at  length  yielding,  only  to  increase  again  and 
again,  it  may  be,  upon  the  recurrence  of  acute  seizures 
of  epigastric  pain.  The  former  type  appears  commonly 
in  those  who  have  before  suffered  little  or  no  abdominal 
trouble,  who  have  been  free  from  all  "indigestion," 
and  in  robust  health  to  the  moment  of  the  onset  of 
jaundice,  and  who  then  rapidly  waste  and  lose  all 
interest  in,  or  capacity  for,  their  ordinary  daily  tasks. 
The  latter  type  appears  always  in  those  who  have 
suffered  long  from  flatulence,  indigestion,  colic,  and  all 
the  characteristic  "inaugural  symptoms"  of  gall-stones. 

The  conditions  which  may  cause  the  first  type  of 
jaundice,  due  to  a  progressive,  unremitting,  and  finally 
complete  obstruction  of  the  duct,  are: 

1.  Carcinoma  of  the  pancreas. 

2.  Carcinoma  of  the  common  hepatic,  cystic,  and 
common  ducts. 

3.  Carcinoma  of  the  ampulla. 

4.  Stricture  of  the  common  hepatic  or  common 
bile-ducts. 

181 


OBSTRUCTIVE  JAUNDICE. 


5.  Stricture  of  the  ampulla  due  to  the  cicatrix  of  a 
duodenal  ulcer. 

6.  Compression  of  the  common  duct  from  without — 
for  example,  by  the  scar  of  a  duodenal  ulcer,  by  a  large 
stone  in  the  cystic  duct,  by  enlarged  glands  in  the  portal 
fissure  or  below  it;  rarely  by  carcinoma  of  the  stomach 
or  duodenum. 

The  conditions  which  may  cause  the  second  type  of 
jaundice,  due  to  an  obstruction,  at  first  perhaps  com- 
plete, but  soon  becoming  incomplete  and  variable,  are : 

1.  Stone  in  the  common  hepatic  or  common  bile-duct. 

2.  Chronic  pancreatitis,  with  or  without  stone. 

3.  Hydatid  cysts  in  the  common  duct. 

4.  Pressure  from  without,  as  in  renal  and  other 
tumours. 

2.  Physical  Signs. — (a)  In  these  two  types  of  case 
the  condition  of  the  gall-bladder  affords  a  sign  helpful 
in  differential  diagnosis.  In  the  former  class  the  gall- 
bladder is  dilated;  in  the  latter,  contracted.  The  recog- 
nition of  this  fact  we  owe  to  Courvoisier.  "Cour- 
voisier's  law,"  as  it  is  called,  asserts  that  "in  cases  of 
chronic  jaundice,  due  to  blocking  of  the  common  duct, 
a  contraction  of  the  gall-bladder  signifies  that  the  ob- 
struction is  due  to  stone;  a  dilatation  of  the  gall-bladder, 
that  the  obstruction  is  due  to  causes  other  than  stone." 
Violations  of  this  law,  as  of  all  clinical  laws,  are  found, 

182 


OBSTRUCTIVE  JAUNDICE. 


but  an  extended  enquiry  revealed  less  than  10  per  cent. 
of  error.  The  errors,  moreover,  are  not  so  significant 
as  this  statement  would  lead  one  to  suppose;  for,  as  a 
rule,  enquiry  into  the  other  conditions  of  the  case 
makes  the  diagnosis  clear.  The  infractions  of  the  la-w- 
are found  in  the  following  circumstances: 

1.  Where  there  is  a  stone  or  a  stricture  in  the  cystic 
duct  causing  hydrops  or  empysema,  together  with  the 
acute  impaction  of  a  stone  in  the  common  duct. 

2.  Where  there  is  a  stone  in  the  cystic  duct  pressing 
upon  the  common  duct. 

3.  Where  there  is  distension  of  the  gall-bladder  by 
an  acute  inflammatory  process,  with  obstruction  of  the 
common  duct  by  stone. 

4.  Where  there  is  chronic  induration  of  the  head  of 
the  pancreas,  with  a  stone  in  the  common  duct. 

5.  Where  there  is  malignant  disease  of  the  common 
duct  at  any  part  of  its  course,  or  cancer  of  the  head  of 
the  pancreas,  and  a  chronic  sclerosing  cholecystitis. 

(6)  The  presence  of  an  ovoid  or  oblong  abdominal 
tumour  in  the  lower  epigastric  region,  or  at  the  junc- 
tion of  the  epigastric  and  right  hypogastric  areas,  is 
significant  of  an  enlargement  of  the  pancreas.  This 
enlargement  may  be  due  to  a  malignant  growth  in  the 
pancreas,  the  swelling  then  being  hard,  a  little  irregu- 
lar and  painless;  or  it  may  be  due  to  a  chronic  inflam- 

183 


OBSTRUCTIVE  JAUNDICE. 


matory  deposit  in  the  gland,  the  sweUing  then  being 
rather  softer  and  decidedly  more  painful.  It  is  rare, 
decidedly,  for  a  malignant  tumour  in  the  head  of  the 
pancreas  to  be  felt  on  examination;  it  is  not  very  in- 
frequent, especially  in  thin  people,  for  an  inflamed  and 
enlarged  pancreas  to  be  palpable. 

(c)  Enlargement  of  the  liver  is  generally  noticed  in 
cases  of  biliary  stasis.  When  the  obstruction  is  inter- 
mittent, as  in  calculous  impaction,  the  variations  in  the 
size  and  in  the  tenderness  of  the  liver  may  easily  be 
recognised.  After  an  acute  seizure  of  pain  the  jaundice 
deepens,  and  the  liver  becomes  larger,  more  easily 
palpable— swollen  in  fact;  and  it  is  decidedly  more 
tender.  Irregular  bosses  on  the  surface  of  the  organ 
are  strongly  indicative  of  carcinoma. 

(d)  The  presence  of  free  fluid  in  the  abdomen  is  very 
suggestive  of  malignant  disease.  In  the  late  stages  of 
cancer  of  the  head  of  the  pancreas,  ascites  with  oedema 
of  the  lower  limbs  is  rarely  absent.  But  ascites  which 
is  due  to  pressure  upon  the  portal  vein  may  result  from 
the  impaction  of  a  stone  of  large  size  in  the  cystic  or 
common  ducts.  In  "Gall-Stones  and  Their  Surgical 
Treatment"  (second  edition,  p.  211)  I  have  recorded  a 
case  in  which  a  large  stone,  fixed  in  the  cystic  duct, 
had  so  compressed  the  portal  vein  and  the  common 
bile-duct  as  to  cause  jaundice  and  ascites,  for  which 

184 


OBSTRUCTIVE  JAUNDICE. 


the  patient  was  several  times  tapped  in  the  beUef  that 
mahgnant  disease  of  the  pancreas  or  Uver  was  present. 
3.  Examination  of  the  Urine  and  Fceces. — The  work  of 
Cammidge  on  the  condition  of  the  urine  and  faeces  in 
cases  of  obstructive  jaundice  and  of  pancreatic  disease 
has,  I  feel  sure,  given  us  great  assistance  in  arriving 
at  a  correct  diagnosis  in  those  difficult  cases  where 
the  ordinary  clinical  signs  leave  one  in  great  perplexity 
and  doubt.  In  the  case  just  quoted,  for  example,  an 
examination  of  the  urine  would  have  shown  the  absence 
of  pancreatic  disease,  and  the  faeces  would  probably 
have  contained  some  small  quantity  of  stercobilin. 
The  characteristic  needle-shaped  crystals  can  be  ob- 
tained from  the  urine  when  treated  by  Cammidge's 
method  in  cases  of  pancreatitis,  acute  or  chronic.  In 
cases  of  malignant  disease  they  are  found  only  in  about 
one-fourth  of  the  cases,  and  in  these  a  zone  of  inflamma- 
tion probably  surrounds  the  cancerous  area.  If  the 
obstruction  to  the  common  duct  is  above  the  pancreas, 
and  is  complete,  no  bile  will  pass  into  the  intestine,  the 
stercobilin  reaction  will  therefore  be  absent  from  the 
faeces,  and  all  the  pancreatic  juice  will  pass  into  the 
bowel.  The  digestion  of  food  will  therefore  be  un- 
affected. A  deficiency  of  pancreatic  juice  is  shown  by 
the  fact  that  the  fat-splitting  process  is  being  inade- 
quately performed,  and  that  consequently  a  large  part 

185 


OBSTRUCTIVE  JAUNDICE. 


of  the  fat,  even  more  than  90  per  cent.,  may  be  dis- 
charged unabsorbed.  If  all  the  bile  passes  into  the 
bowel  and  the  pancreatic  juice  is  prevented  from  doing 
so,  the  stools,  as  Claude  Bernard  and  Walker  have 
shown,  are  colourless,  probably  because  of  the  large 
amount  of  undigested  fat  which  they  contain.  No 
better  example  of  the  value  of  Cammidge's  methods 
could  be  found  than  in  the  record  of  the  following  case: 

J.  D.,  male,  aged  fifty.  Complains  of  jaundice  of  great 
intensity.  Until  nearly  the  end  of  July  was  quite  well;  at  that 
time  began  to  suffer  from  flatulence  and  distension  after  food. 
Pain  never  acute  or  colicky;  no  vomiting.  Occasionally  periods 
of  relief  for  a  few  days,  but  the  attacks  continued  to  return 
until  six  weeks  ago,  when  he  became  jaundiced.  Since  then 
pain  has  been  absent,  but  jaundice  has  gradually  deepened. 
There  has  been  no  pyrexia,  no  rigors,  nor  does  he  think  the 
jaundice  has  lessened  in  intensity.     Has  lost  2  st.  in  weight. 

State  on  Examination. — The  liver  is  felt  to  be  enlarged,  and 
is  smooth  and  regular.  The  gall-bladder  can  be  indistinctly 
felt;  it  does  not  project  far  beyond  the  liver  border.  Just 
above  the  umbiHcus  an  indistinct  mass  was  felt  on  one  occasion 
which  suggested  an  enlarged  pancreas. 

The  Urine  and  Fceces  (Report  by  Dr.  Helen  G.  Stewart). — A 
well-marked  pancreatic  reaction  in  the  urine  points  to  some 
degree  of  chronic  pancreatitis,  which  is  confirmed  by  examina- 
tion of  faeces.  There  is  a  high  percentage  of  total  fats,  of  which 
nearly  half  are  combined  fatty  acids,  indicating  that  although 
the  pancreas  is  affected,  occlusion  of  the  pancreatic  duct  is  not 
complete,  and  the  obstruction  to  the  common  bile-duct  must 
be  above  its  junction  with  the  pancreatic.  That  obstruction 
of  the  common  duct  is  almost  complete  is  shown  by  the  presence 
of  only  a  trace  of  stercobiUn  in  the  faeces;    but  the  absence  of 

186 


OBSTRUCTIVE  JAUNDICE. 

undigested  matter  in  the  faeces  also  supports  the  conclusion  that 
the  primary  site  of  the  disease  is  in  the  common  bile-duct  and 
not  in  the  pancreas. 

Diagnosis. — The  case  was  diagnosed  as  one  of  obstruction  of 
the  common  bile-duct  at  a  point  above  the  bile  papilla  from 
some  other  cause  than  carcinoma  of  the  pancreas. 

Operation,  October  13,  1908. — The  Hver  was  enlarged  and 
gall-bladder  much  distended,  with  thickened  walls,  although  it 
did  not  project  beyond  the  lesser  margin  for  more  than  a  short 
distance.  Common  duct  dilated  as  far  as  upper  margin  of 
duodenum.  There  was  an  indurated  scar  in  the  duodenal  wall 
which  involved  the  duct  and  compressed  it  to  complete  obstruc- 
tion. The  scar  was  adherent  to  and  seemed  to  involve  the 
adjacent  part  (only)  of  the  head  of  the  pancreas.  No  tumour 
of  the  head  of  the  pancreas.  No  calculi  palpable.  Gall-bladder 
aspirated  and  found  to  contain  clear  mucus  only.  It  was 
decided  to  perform  a  cholecystenterostomy.  The  duodenum 
could  not  be  brought  up  to  the  gall-bladder  without  dangerous 
tension,  and  so  the  anastomosis  was  made  between  the  gall- 
bladder and  transverse  colon.     Wound  closed. 

The  patient  was  sent  by  Dr.  Dunderdale  (Blackpool),  who 
reports  in  March,  1909:  "He  is  somewhat  sallow,  his  appetite 
is  good,  and  he  has  gained  2  st.  since  the  operation.  Between 
December  28,  1908,  and  January  5,  1909,  had  three  attacks 
of  colicky  pain  over  the  gall-bladder  region,  followed  by  eleva- 
tion of  temperature  and  jaundice  lasting  three  or  four  days.  He 
now  appears  to  be  quite  free  from  all  his  former  inconvenience. 
The  urine  contains  no  bile.  The  pancreatic  reaction  has  almost 
disappeared." 


Selection  of  Cases  for  Operation. 

The  selection  of  the  cases  suitable  to  operation  de- 
pends exclusively  upon  the  accuracy  with  which  a 

187 


OBSTRUCTIVE  JAUNDICE. 


diagnosis  can  be  made.  The  conditions  most  com- 
monly met  with  are  carcinoma  of  the  pancreas,  chronic 
pancreatitis,  and  gall-stones  impacted  in  the  common 
ducts. 

In  carcinoma  of  the  head  of  the  pancreas  the  first 
type  of  jaundice  with  insidious  onset,  and  finally  be- 
coming absolute,  is  characteristic.  The  gall-bladder 
is  constantly  palpable,  petechial  haemorrhages  or  even 
large  subcutaneous  effusions  of  blood  occur,  and  rapid 
and  severe  wasting,  loss  of  appetite  and  all  energy, 
and  anaemia  are  constant  features.  The  pulse,  as  a 
rule,  is  slow;  the  itching  of  the  skin  intolerable;  ascites 
with  oedema  of  the  legs  and  abdomen  comes  at  the  last. 
When  the  urine  is  examined,  the  ''pancreatic"  reaction 
indicative  of  an  inflammatory  change  is  absent  in  the 
great  majority  of  cases;  in  the  minority  it  is  found, 
and  in  them  it  is  probably  always  the  case  that,  in 
addition  to  the  carcinomatous  deposit,  an  inflammatory 
condition  in  the  parts  of  the  gland  immediately  adjacent 
has  recently  developed.  The  faeces  very  rarely  show 
any  evidence  of  stercobilin.  This  is  due  to  the  fact 
that  it  is  not  usual  for  a  case  to  be  submitted  for 
examination  in  the  early  stages,  when  the  compression 
of  the  common  duct  is  slight.  In  the  later  stages,  when 
no  drop  of  bile  can  pass  through  into  the  intestine,  the 
stercobilin  reaction  cannot  of  course  be  obtained.     In 

188 


OBSTRUCTIVE  JAUNDICE. 


cases  of  incomplete  obstruction  of  the  duct  by  a  stone, 
the  presence  of  stercobilin,  though  possibly  in  very 
small  quantities,  is  constant. 

Chronic  pancreatitis  is,  of  course,  most  often  found 
in  association  with  cholelithiasis,  and  usually  with,  or 
sequent  upon,  the  presence  of  a  stone  in  the  common 
duct.  It  is  now  well  known  that  the  effect — chronic 
inflammation  of  the  pancreas — may  long  survive  the 
cause — a  gall-stone;  but  it  is  not  so  generally  recog- 
nised that  the  inflammation  of  the  gland  may  progress 
insidiously  even  though  the  irritant  which  initiated  it 
has  been  removed.  So,  finally,  the  pancreas  is  scler- 
osed, and  diabetes  may  result.  The  recognition  of  the 
presence  of  gall-stones  at  an  early  stage  and  their 
removal  is,  therefore,  the  surest  means  of  preventing 
the  development  of  chronic  inflammation  of  the  pan- 
creas. There  are  clinically  two  types  of  chronic  pan- 
creatitis; in  the  first  the  symptoms  and  signs  approxi- 
mate to  those  of  carcinoma  of  the  pancreas;  in  the 
second,  to  those  of  intermittent  calculous  obstruction 
of  the  duct.  In  the  former  the  jaundice  is  sometimes 
very  deep,  but  is  rarely  complete  or  unremitting.  The 
tinge  may  vary  in  depth,  even  during  the  course  of  a 
single  day,  or  may  ebb  and  flow  so  slightly  as  just  to  be 
recognised.  The  gall-bladder  is  then  distended  by 
bile,  not  by  mucus.     The  faeces  are  abundant,  frequent, 

189 


OBSTRUCTIVE  JAUNDICE. 


soft,  and  greyish-white  in  colour,  and  greasy  in  ap- 
pearance by  reason  of  the  great  excess  of  neutral  fat 
which  is  undigested  and  unabsorbed.  Stercobilin  is 
present  and  the  urine  gives  the  Cammidge  reaction. 
The  duration  of  the  disease  and  the  absence  of  the 
extreme  cachexia  help  to  distinguish  the  simple  from 
the  cancerous  condition. 

In  the  second  form  there  are  the  varying  jaundice, 
the  occasional  rigors  and  sweating,  the  rapid  elevations 
and  depressions  of  temperature  which  characterise  a 
case  of  chronic  obstruction  of  the  common  bile-duct; 
but  all  these  things  seem  rather  less  in  degree.  Pain  is 
not  severe,  and  is  rather  a  sense  of  epigastric  oppression 
and  uneasiness  than  an  acute  agonising  colic. 

In  cases  of  acute  calculous  obstruction  of  the  common 
bile-duct  a  difficulty  of  differentiation  from  carcinoma 
of  the  pancreas  may  well  be  experienced,  for  the  jaun- 
dice is  deep  and  progressive  in  both.  The  history, 
however,  gives  the  surest  clue.  With  few  exceptions, 
pain  is  absent  in  carcinoma,  and  is  present  in  high 
degree  before  the  onset  of  jaundice  due  to  a  stone. 
In  the  former  the  jaundice  appears  insidiously,  in  the 
latter  rapidly.  A  stone  does  not  lie  long  in  the  duct, 
however,  before  secondary  changes  appear;  the  duct 
dilates,  and  the  stone  comes  to  fit  loosely.  Then 
appear  the  signs  so  characteristic  of  the    *' floating" 

190 


OBSTRUCTIVE  JAUNDICE. 


stone — attacks  of  severe  epigastric  pain  of  a  colicky 
character,  rigors,  "steeple"  elevations  of  temperature, 
and  the  rapid  transient  deepening  of  a  jaundice  which 
never  entirely  clears  away.  The  gall-bladder  is  con- 
tracted as  a  result  of  many  old  attacks  of  cholecystitis, 
and  is  therefore  never,  or  very  rarely,  palpable.  Wast- 
ing is  often  extreme;  in  one  of  my  cases  there  was  a 
loss  of  12  st.  in  weight — from  22  st.  to  10  st.  Within 
six  months  of  operation  7  st.  of  this  loss  were  recovered. 
The  liver  is  almost  always  enlarged,  and  is  especially 
so  immediately  after  an  attack  of  pain.  It  is  smooth, 
and  there  are  no  irregularities  upon  its  surface.  In 
the  intervals  of  the  attacks  of  pain  the  patient  often 
feels  well  and  may  gain  a  little  in  weight;  constipation 
is  usually  present  at  all  times.  A  point  upon  which 
stress  has  been  laid  as  distinguishing  gall-stone  im- 
paction from  chronic  pancreatitis  is  that  in  the  former 
the  radiating  pain  is  to  the  right,  in  the  latter  to  the 
left.  I  have  not  found  that  any  reliance  can  be  placed 
upon  this. 

When  carcinoma  affects  the  hepatic  or  common 
bile-ducts,  or  the  ampulla  of  Vater,  the  symptoms 
strongly  resemble  those  due  to  cancer  of  the  head  of 
the  pancreas. 

There  is,  however,  a  possibility  of  making  an  ac- 
curate diagnosis  by  giving  attention  to  the  history,  and 

191 


OBSTRUCTIVE  JAUNDICE. 


by  making  use  of  Cammidge's  methods.  The  history 
points  more  frequently  to  gall-stone  disease;  in  car- 
cinoma of  the  pancreas,  as  I  have  seen  it,  a  history  of 
cholelithiasis  is  very  rare,  nor  are  stones  found  in  the 
ducts  or  in  the  gall-bladder  at  operation  or  autopsy. 
In  cancer  of  the  larger  bile-ducts  stones  are  found, 
though  by  no  means  so  frequently  as  in  cancer  of  the 
gall-bladder.  Rolleston  found  stones  present  in  23 
out  of  62  cases  of  primary  carcinoma  of  the  bile-ducts. 
In  both  cancer  of  the  pancreas  and  cancer  of  the  com- 
mon bile-duct  the  gall-bladder  is  usually  distended. 
Devic  and  Gallavardin  in  18  cases  of  primary  carcin- 
oma of  the  common  duct  found  that  the  gall-bladder 
was  enlarged  in  17.  The  examination  of  the  urine  and 
fseces  should  enable  a  diagnosis  to  be  made  if  the  growth 
in  the  ducts  is  above  the  papilla,  for  the  canal  of  Wir- 
sung  is  then  free,  and  the  pancreatic  juice  can  flow 
unimpeded  into  the  intestine.  The  ''pancreatic  re- 
action" is  negative;  no  stercobilin  is  present. 

Simple  stricture  of  the  common  hepatic  duct  or 
common  bile-duct  may  result  from  the  healing  of  an 
ulcer  due  to  a  gall-stone,  as  in  a  case  of  my  own,  or  it 
may  occur  independently  of  gall-stones  as  a  sequence 
to  typhoid  or  other  infection.  In  my  case,  a  diagnosis 
of  obstruction  of  the  duct,  due  possibly  to  stricture 


192 


OBSTRUCTIVE  JAUNDICE. 


following  an  old  calculous  obstruction,  was  made  upon 
the  history  alone. ^ 

Operative  Procedure. 

The  operations  practised  for  obstructive  jaundice 
are  concerned  either  with  the  direct  removal  of  the 
impediment,  or  with  the  making  of  an  alternative  path 
for  the  bile,  or  in  certain  cases  with  prolonged  drainage 
of  the  bladder  and  ducts. 

The  following  are  the  procedures : 

(A)  Removal  of  the  Obstruction. — (a)  Choledocho- 
tomy;   (6)  Choledochectomy;   (c)  Choledochoplasty. 

(B)  Short-circuiting  Operations. — (a)  Cholecysten- 
terostomy;  (6)  Hepatico-duodenostomy;  (c)  Cystico- 
duodenostomy;  id)  Choledocho-duodenostomy;  (e) 
Hepato-cholangio-duodenostomy. 

(C)  Drainage  Operations. — (a)  Cholecystostomy;  (6) 
Choledochostomy. 

In  cases  of  prolonged  jaundice  a  tendency  to  haemor- 
rhage has  been  noticed.  Petechial  haemorrhages,  or 
even  large  effusions  of  blood  beneath  the  skin,  may 
occur.  During  an  operation  every  smallest  vessel  may 
ooze  continuously,  and  after  the  wound  has  been  closed 
bleeding  may  go  on  quietly  between  the  stitches,  or 
haemorrhage  may  occur  within  the  abdomen  near  to, 
or  at  some  distance  from,  the  parietal  incision.  There 
13  193 


OBSTRUCTIVE  JAUNDICE. 


are  those  who  beheve  that  the  haemorrhage  is  more 
likely  to  occur,  and  is  of  more  significance  if  the  pan- 
creas is  involved,  but  I  have  not  been  convinced  that 
there  is  evidence  for  this  belief.  In  some  cases  of 
prolonged  bihary  obstruction  the  coagulation  time  of 
the  blood  may  be  lengthened,  but  this  is  not  often  or 
even  usually  the  case,  and  I  have  known  it  to  be  short- 
ened.* But  of  the  tendency  to  haemorrhage  in  a  few 
cases,  whatever  the  coagulation  time  may  be,  there 
can  be  no  doubt.  And  the  question  at  once  arises  as 
to  whether  anything  can  be  done  to  forestall  or  counter- 
act this.  A.  E.  Wright  suggested  many  years  ago  that 
calcium  chloride  would  increase  the  coagulability  of 
the  blood,  and  Mayo  Robson  and  others  have  consist- 
ently advocated  the  use  of  the  salt,  and  have  quoted 
cases  in  which  they  beheved  it  to  have  been  of  value. 
My  own  view  is  that  no  good  comes  of  its  use;  the 
evidence  seems  insufficient.  It  is  well  known  that  the 
coagulation  of  the  blood  in  any  species  is  greatly  ac- 
celerated by  the  injection  of  an  alien  serum,  and  upon 
this  fact  I  have  based  the  practice  of  injecting  sterilized 
horse  serum  (diphtheria  antitoxin  will  do  in  an  emer- 

♦An  important  point  in  differential  diagnosis  is,  I  think, 
coming  from  this  work.  A  coagulation  time  of  eight  or  nine 
minutes  or  more  is  rarely  found  in  simple  cases  and  is  common 
in  malignant  conditions.  When  other  signs  and  symptoms  leave 
the  differential  diagnosis  in  doubt,  this  may  give  conclusive  help. 

194 


OBSTRUCTIVE  JAUNDICE. 

gencjO  before  operation  upon  jaundiced  patients.  It 
may  be  coincidental,  but  it  is  true,  that  since  doing  so 
haemorrhage  has  not  occurred  in  any  case  of  mine  (the 
effect  of  the  serum  was  marked  in  the  case  of  a 
''bleeder"  who  had  had  two  teeth  extracted  and  had 
bled  almost  to  death).  J.  C.  Munro^  has  administered 
fresh  rabbit  serum  in  doses  of  30  c.c.  subcutaneously 
twenty-four  hours  before  operation  in  fifteen  or  tv/enty 
patients,  some  of  whom  were  purpuric,  without  seeing 
''the  least  tendency  to  oozing  except  in  one  or  two  in- 
stances, w^hen  it  was  checked  at  once  by  the  use  of  more 
serum."  Further  experience  of  the  use  of  these  alien 
serum  injections  is  necessary  before  their  real  worth 
can  be  estimated;  but,  so  far  as  I  have  been  able  to 
see,  I  think  that  they  are  the  most  reliable  of  all 
methods. 

1.  Operations  Concerned  with  the  Removal  of  the  Ob- 
struction.— These  are  now,  as  a  rule,  easily  performed, 
and  the  results,  both  immediate  and  remote,  are  very 
satisfactory.  The  position  of  the  patient,  the  back 
being  arched  over  a  cushion  placed  behind  the  liver, 
and  the  upward  and  outward  displacement  of  the  right 
lobe  of  the  liver  make  the  approach  to  the  common 
duct  very  much  easier.  The  bile  in  the  common  duct 
is  usually  infected;  in  more  than  half  the  cases  a  cul- 
ture of  an  organism  can  be  obtained;   it  is  therefore 

195 


OBSTRUCTIVE  JAUNDICE. 


necessary  to  protect  all  parts  within  the  abdomen  and 
the  abdominal  wall  also  from  infection.  The  duct  may 
be  exposed  by  the  free  separation  of  all  adhesions 
around  and  about  it,  or,  if  the  patient's  condition  be 
very  poor,  by  the  method  of  ''rotation  of  the  duct" 
which  I  have  described  elsewhere.  The  duct  being 
opened  and  to  all  appearance  cleared  of  obstruction, 
the  finger  must  be  introduced  to  explore  the  interior, 
for  in  no  other  way  can  it  be  made  certain  that  all  stones 
have  been  removed.  The  duct  should  always  be 
drained  by  a  tube  which  passes  upwards  to  the  hepatic 
duct;  it  is  never  prudent  to  attempt  its  complete 
closure  by  suture.  The  gall-bladder  also  may  be 
drained;  it  is  never  wise  to  remove  it  in  these  cases 
unless  it  is  useless  or  diseased  beyond  power  of  re- 
covery. The  results  of  choledochotomy  followed  by 
drainage  are  most  satisfactory.  The  mortality  is  now 
about  5  per  cent.,  and  the  after-history  is  almost  always 
free  from  incident.  I  have  only  once  had  to  operate 
a  second  time  on  a  patient  whose  common  duct  had 
been  opened  and  drained,  by  myself,  for  calculous 
obstruction. 

2.  Short-circuiting  Operations. — In  malignant  disease 
of  the  head  of  the  pancreas,  for  example,  short-circuit- 
ing operations  are  hardly  justifiable  in  the  average 
case.     Every  aspect  of  the  case  is  unfavourable.     The 

196 


OBSTRUCTIVE  JAUNDICE. 


patient  is  ill,  wasted,  extremely  feeble;  his  blood  con- 
dition is  bad,  and  the  tendency  to  haemorrhage  is 
remarkable;  the  relief  obtained  by  operation,  of  what- 
ever kind,  is  slight,  and  does  not  justify  the  desperate 
risk. 

The  one  distressing  symptom  which  urges  the  patient 
to  cry  for  relief  is  itching  of  the  skin.  This  is  an  in- 
tolerable torment.  To  give  some  ease  to  it  by  any 
outward  application  is,  I  believe,  almost  impossible. 
The  surgeon  may  therefore  be  persuaded  to  attempt 
relief  by  cholecystostomy  or  by  cholecystenterostomy. 
The  former  operation  I  have  several  times  done  under 
eucaine  or  novocain  anaesthesia.  The  gall-bladder  is 
large,  and  the  operation  rapid  and  easy.  The  relief 
occasionally  is  considerable,  though  it  may  be  many 
days  before  bile  begins  to  flow  freely,  the  functions  of 
the  liver  have  been  so  long  suppressed.  Cholecysten- 
terostomy for  these  cases  is  a  dangerous  operation; 
its  mortality  would  appear  to  be  near  to  75  per  cent. — 
almost  prohibitive.  But  if  the  disease  is  recognised 
early,  and  the  patient's  condition  be  otherwise  favour- 
able for  operation,  a  rare  case  for  surgical  treatment 
may  be  encountered.  The  relief  then  (in  no  more 
than  three  cases  of  my  own)  is  great,  and  the  awful 
distress,  inevitable  if  jaundice  develops  deeply,  may 
be  entirely  avoided.     Some  faint  tinge  of  yellowness, 

197 


OBSTRUCTIVE  JAUNDICE. 


however,  remains  in  the  skin,  but  the  itching,  even 
when  felt,  is  never  unbearable. 

The  operation  of  cholecystenterostomy  finds  its  most 
suitable  application  in  cases  where  the  obstruction  of 
the  duct  is  considerable,  likely  to  be  permanent,  and 
is  of  a  non-malignant  character.  Chronic  pancreatitis 
is  certainly  the  disease  most  often  needing  this  relief. 
But  here  a  word  of  warning  is  needed.  The  range  and 
the  role  of  chronic  pancreatitis  must  not  be  unduly 
enlarged.  It  is  a  very  real  disease,  but  it  is  not  to  be 
diagnosed  in  any  rough  and  haphazard  manner.  I 
have  known  cases  in  which  large  stones  were  present 
in  the  lower  part  of  the  common  duct  treated  by  a  short- 
circuiting  operation,  the  concomitant  enlargement  and 
induration  of  the  head  of  the  pancreas  being  then 
attributed  to  chronic  inflammation.  A  very  sufficient 
examination  of  the  common  duct  is  necessary  before 
the  presence  of  stones  can  be  excluded,  and  a  prelimin- 
ary examination  of  the  urine  and  f  seces  must  have  been 
made  in  most  cases  before  a  diagnosis  of  pancreatitis 
can  be  confidently  established.  In  the  great  majority 
of  instances  chronic  pancreatitis  is  almost  a  negligible 
complication  of  cholelithiasis.  The  treatment  of  the 
gall-bladder  or  of  the  ducts  will  then  sufl^ce  to  relieve 
the  lesion  in  the  pancreas,  which  is  secondary.  The 
drainage  for  two  or  three  weeks  of  the  bile-passages 

198 


OBSTRUCTIVE  JAUNDICE. 


is  all  that  is  needed.  But  there  are  cases  in  which  long 
after  the  stones  have  passed  the  pancreatic  inflamma- 
tion endures,  and  in  such  cases  an  anastomosis  between 
the  gall-bladder,  which  is  often  distended,  and  the 
duodenum  may  alone  be  competent  to  give  relief.  In 
my  own  work  I  look  upon  the  need  for  cholecystenter- 
ostomy  as  very  restricted,  partly  because  the  great 
majority  of  cases  are  equally  well  treated  by  less  serious 
means,  partly  because  I  am  doubtful  of  the  permanence 
of  the  drainage  by  a  short  circuit  in  the  absence  of 
complete  obstruction,  and  partly  because  I  do  not  feel 
sure  that  in  some  cases  an  escape  of  organisms  from 
the  intestine  to  the  bile-passages  may  not  occur.  This 
last  objection  is,  of  course,  reduced  to  the  smallest 
proportion  if  the  duodenum  is  selected  for  the  anasto- 
mosis; unhappily  this  is  not  always  possible,  the  jeju- 
num or  even  the  colon  being  sometimes  more  accessible. 
The  operation  is  one,  therefore,  of  restricted  use;  it 
finds  its  surest  application  in  the  obstructions  which  are 
complete  and  permanent,  and  it  is  most  aptly  applied 
when  the  duodenum  is  accessible  for  the  anastomosis. 
The  operations  by  which  the  main  bile-channels  are 
anastomosed  to  the  intestine  (hepatico-duodenostomy, 
cystico-duodenostomy,  and  choledocho-duodenostomy) 
are  rarely  necessary.  They  are  performed  either  after 
the  removal  of  a  stricture  (simple  or  malignant)  of  the 

199 


OBSTRUCTIVE  JAUNDICE. 


ducts  or  when  operation  defects  are  present.  Dr.  W. 
J.  Mayo  has  demonstrated  the  best  methods  of  their 
performance  and  the  chief  indication  for  their  employ- 
ment. 

REFERENCES. 

1.  British  Medical  Journal,  1905,  vol.  ii,  p.  1390. 

2.  Boston  Med.  and  Surg.  Journal,  March  25,  1909,  p.  363. 


200 


On  the  Violation  of  Courvoisier's 

Law.* 

The  differential  diagnosis  in  cases  of  obstructive 
jaundice  may  be  difficult,  and  is  sometimes  impossible. 
In  order  to  increase  our  chances  of  accurate  diagnosis 
to  the  fullest  extent,  the  closest  attention  must  be  paid 
to  every  separate  symptom  and  to  every  different 
grouping  of  the  individual  symptoms.  The  most  im- 
portant clinical  aid  to  diagnosis  is  that  which  is  now 
generally  known  as  ''Courvoisier's  law."  The  facts 
upon  which  this  law  is  based  were  first  collected  by 
Courvoisier,  and  are  given  in  detail  by  him  in  his 
monumental  work.^ 

Recently  the  ''law"  has  been  associated  with  the 
name  of  Terrier;  and  is  referred  to  as  ''Terrier's  law," 
or  "the  Courvoisier-Terrier  Law,"  but  the  French 
surgeon  has  not  the  least  claim  to  priority  in  this 
matter;  the  credit  of  the  work  accomplished  is  to  be 
given  to  Courvoisier  alone.  Terrier  himself,  indeed, 
acknowledges  that  the  first  enunciation  and  demon- 
stration of  the  law  were  due  to  Courvoisier.^ 

*  Reprinted  from  the  Edinburgh  Medical  Journal,  May,  1906. 

201 


COURVOISIER'S  LAW. 


The  details  given  by  Courvoisier  upon  which  the  law 
is  based  are  as  follows: 

Up  to  the  time  when  his  review  of  the  literature  was 
made,  there  were  recorded  187  cases  of  obstruction  of 
the  common  duct  from  all  causes.  Of  these,  100  were 
due  to  obstruction  from  causes  other  than  stone,  and 
87  were  due  to  obstruction  by  stone.  Of  100  cases  in 
which  the  obstruction  was  due  to  causes  other  than 
stone,  in  92  cases  there  was  dilatation  of  the  gall- 
bladder; in  8  cases  there  was  a  normal  gall-bladder, 
or  an  atrophy  of  the  gall-bladder.  Of  87  cases  in  which 
the  obstruction  was  due  to  stone,  in  70  cases  the  gall- 
bladder was  small  and  atrophied;  in  17  cases  the  gall- 
bladder was  dilated. 

All  these  cases  were  collected  from  post-mortem 
records.  Of  the  cases  that  had  been  submitted  to 
operation,  35  in  number,  in  18  the  obstruction  was  due 
to  causes  other  than  stone,  and  in  16  of  these  there  was 
dilatation  of  the  gall-bladder;  in  17  the  obstruction 
was  due  to  stone,  and  in  13  of  these  the  gall-bladder 
was  contracted. 

These  facts  were  summarised  by  Courvoisier  and 
may  be  embodied  as  a  *'law"  in  the  following  state- 
ment: 

''In  cases  of  chronic  jaundice  due  to  obstruction  of 
the  common  bile-duct,  a  contraction  of  the  gall-bladder 

202 


COURVOISIER'S  LAW 


signifies  that  the  obstruction  is  due  to  stone;  a  dilata- 
tion of  the  gall-bladder,  that  the  obstruction  is  due  to 
causes  other  than  stone." 

Independent  confirmation  of  this  law  was  made  by 
Terrier  and  by  Mayo  Robson;  subsequent  writers, 
without  exception,  have  corroborated  it,  and  have 
quoted  exemplary  instances  of  its  accuracy. 

Ecklin,  in  172  cases  of  common  duct  obstruction  due 
to  calculus,  found  that  28,  or  16  per  cent.,  had  dilata- 
tion of  the  gall-bladder;  144,  or  84  per  cent.,  had 
contraction  of  the  gall-bladder.  In  139  cases  of  ob- 
struction due  to  other  causes,  121,  or  87  per  cent.,  had 
dilatation  of  the  gall-bladder. 

A  further  examination  of  the  question  has  been  made 
by  Dr.  A.  Cabot,  of  Boston,  who  collected  the  records 
of  the  Massachusetts  Hospital  for  a  series  of  years. 
There  were  86  cases  of  obstruction  of  the  common  duct. 
Of  these,  57  were  due  to  obstruction  by  stone;  in  47 
the  gall-bladder  was  atrophied,  in  8  it  was  normal,  and 
in  2  enlarged.  Twenty-nine  cases  were  due  to  causes 
other  than  stone;  in  27  the  gall-bladder  was  distended; 
in  one  the  gall-bladder  was  empty,  and  in  one  contracted 
around  three  stones.  Only  4  cases,  therefore,  in  this 
series  did  not  fall  in  with  Courvoisier's  law.  Cabot 
writes:  "With  the  exception  of  these  four  cases,  which 
constitute  only  5  per  cent,  of  the  total  number  exam- 

203 


COURVOISIER'S  LAW. 


ined,  every  record  of  the  Massachusetts  Hospital  series, 
in  which  definite  statements  are  to  be  found  concerning 
the  points  at  issue,  goes  to  confirm  Courvoisier's  law." 

The  explanation  given  originally  by  Courvoisier  of 
the  occurrence  of  the  sclerosis  of  the  gall-bladder  in 
cases  of  calculous  obstruction  of  the  duct  was,  that 
stones  had  been  present  in  the  gall-bladder  for  long 
periods,  that  their  presence  there  had  caused  recurring 
attacks  of  cholecystitis,  and  that,  as  a  result,  the  gall- 
bladder walls  had  become  thickened  and  fibrous.  The 
gall-bladder,  so  affected,  became  by  degrees  more  and 
more  shrunken,  and  at  the  last  was  represented  by  a 
shrivelled  mass  of  fibrous  tissue,  its  cavity  was  greatly 
reduced  in  size,  or  almost  obliterated,  and  the  surround- 
ing dense  adhesions  hid  it  from  sight.  Oft-repeated 
attacks  of  cholecystitis  and  peritonitis  resulted  in 
the  cicatricial  compression  and  cramping  of  the  gall- 
bladder. Distension  of  such  a  gall-bladder  is,  of  course, 
mechanically  impossible. 

Fenger,  criticising  this  statement,  offers  the  explana- 
tion that  "the  atrophy  in  these  cases,  hitherto  im- 
comprehensible,  is  easily  explained  by  the  ball-valve 
action  of  a  floating  choledochus  stone  at  the  distal  end 
of  the  cystic  duct."  This,  however,  leaves  out  of  con- 
sideration the  numerous  cases  where  the  stone  is  not 
found  at  the  spot  mentioned.     Elsewhere  Fenger  attri- 

204 


COURVOISIER'S  LAW. 


butes  the  emptiness  of  the  gall-bladder  to  a  floating 
stone  ''in  or  near  the  cystic  duct." 

The  great  probability  is  that  the  explanation  of 
Courvoisier  is  entirely  correct.  The  sclerosis  (it  is  not 
merely  an  "atrophy,"  as  Fenger  says)  of  the  gall- 
bladder is  a  matter  of  old  standing,  and  is  present  long 
before  the  impaction  of  the  stone.  Fenger's  explana- 
tion would  account  for  the  emptiness  of  the  gall-bladder 
in  a  few  cases,  but  not  for  the  cicatricial  contraction 
present  in  the  great  majority. 

In  cases  of  obstruction  of  the  common  duct,  when  the 
jaundice  is  persistent  and  unvarying,  when  it  does  not 
"ebb  and  flow,"  a  dilatation  of  the  gall-bladder  very 
strongly  suggests  a  diagnosis  of  malignant  disease, 
probably  in  the  head  of  the  pancreas,  but  possibly  in 
the  common  bile-duct  itself.  But  the  association  of 
chronic  jaundice  and  enlargement  of  the  gall-bladder 
does  not  always  mean  that  cancer  is  present  or  that 
stone  is  absent.  The  "law"  may  be  infringed,  some- 
times flagrantly,  as  Courvoisier  himself  was  the  first 
to  assert. 

In  the  great  majority  of  the  cases  that  have  come 
under  my  own  observation,  Courvoisier's  law  has 
proved  to  be  correct.  Some  of  these  cases  have  been 
submitted  to  operation,  and  the  diagnosis  verified  in 
that  way,  but  many  of  them,  after  the  opinion  has  been 

205 


COURVOISIER'S  LAW. 


expressed  that  malignant  disease  was  present,  have  been 
deliberately  left  without  operation;  the  subsequent 
clinical  course  and  post-mortem  examination  have 
shown  that  the  diagnosis  was  accurate. 

To  achieve  an  accurate  diagnosis  in  cases  of  chronic 
obstructive  jaundice  is  of  the  first  importance,  for  if 
the  disease  is  simple,  an  operation  will  cure  the  patient; 
if  the  disease  is  malignant,  the  operation  in  itself  is 
productive  of  great  harm,  and  no  possible  benefit  can 
be  expected  from  it.  But  little  attention  has  been 
given  to  the  conditions  which  are  disclosed  when  there 
is  an  infraction  of  Courvoisier's  law.  Several  cases 
have  come  under  my  own  care  in  which  chronic  jaun- 
dice and  distension  of  the  gall-bladder  have  been 
associated,  in  the  absence  of  malignant  disease,  and 
at  least  two  in  which  cancer  of  the  head  of  the  pancreas 
was  found  at  operation,  and  subsequently  verified  by 
microscopic  examination  when  no  distension  of  the 
gall-bladder  was  present.  In  one  case  I  have  operated 
for  carcinoma  of  the  common  bile-duct,  the  gall-bladder 
being  sclerosed. 

Courvoisier  calls  attention  (p.  59)  to  several  cases 
in  which  hydrops  or  empyema  of  the  gall-bladder  due 
to  stone  in  the  cystic  duct,  or  to  stenosis  of  the  duct, 
was  present  when  there  was  calculous  obstruction  of 
the  common  duct. 

206 


COURVOISIER'S  LAW. 


The  following  are  brief  extracts  from  the  notes  of 
some  cases  under  my  care  in  which  there  was  a  trans- 
gression of  Courvoisier's  "law:" 

Group  1. — Cases  of  chronic  obstructive  jaundice 
associated  with  distension  of  the  gall-bladder,  in  the 
absence  of  malignant  disease. 

Case  1. — Empyema  of  the  gall-bladder  due  to  impaction  of  a 
stone  in  the  cystic  duct;  obstructive  jaundice  due  to  stone  in  the  com- 
mon duct. — The  patient  was  a  woman,  aged  fifty-eight,  who  for 
many  years  had  suffered  from  attacks  of  "spasms,"  which, 
since  her  child-bearing  period,  had  been  very  much  less  severe 
than  they  were  previously.  In  April,  1904,  there  were  a  series 
of  attacks  of  severe  pain  in  the  right  hypochondrium,  two  of 
which    were   followed   by   transient   jaundice.     In   September, 

1904,  she  became  deeply  jaundiced,  and  from  that  time  up  to 
April,  1905,  the  jaundice  had  varied  very  httle  from  time  to 
time.     Ten  days  before  her  admission  to  the  Infirmary  in  April, 

1905,  she  had  a  rigor,  a  temperature  of  104.2°,  and  a  swelhng 
was  then  first  noticed  in  the  abdomen. 

On  admission  the  patient  was  deeply  jaundiced.  Her  tem- 
perature varied  between  98°  and  100°  in  the  morning,  and 
between  100°  and  102°  at  night.  During  seven  days  when  she 
was  under  observation,  the  jaundice  did  not  vary  in  the  least. 
There  was  pain  in  the  right  hypochondrium,  and  on  examina- 
tion a  large  ovoid  mass  could  be  felt.  It  was  smooth  and  tender, 
and  was  recognised  as  a  distended  gall-bladder.  On  the  ninth 
day  after  admission  a  rigor  occurred;  the  abdomen  became  full 
and  tender.  Operation  was  undertaken,  an  empyema  of  the 
gall-bladder  found,  due  to  a  stone  impacted  in  the  cystic  duct. 
In  the  third  part  of  the  common  duct  a  stone  as  large  as  a  pigeon's 
egg  was  felt.  It  was  pushed  backwards  in  the  first  part  of  the 
duct  and  removed.  The  gaU-bladder  was  drained,  the  stone 
in  the  cystic  duct  being  easily  dislodged.     The  patient  recovered. 

207 


COURVOISIER'S  LAW. 


Case  2. — Hydrops  of  the  gall-bladder;  obstructive  jaundice 
due  to  many  stones  impacted  in  the  common  duct. — A  lady,  aged 
fortj^'-eight,  had  suffered  from  jaundice  for  fifteen  months. 
The  jaundice  had  come  on  without  pain,  and  had  not  varied  after 
the  first  month.  After  nine  months  of  jaundice  the  opinion 
was  expressed  by  a  distinguished  physician  that  there  was 
malignant  disease  of  the  pancreas,  for  examination  disclosed  a 
distended  gall-bladder.  A  fortnight  before  I  saw  her  in  January, 
1906,  there  had  been  a  sharp  attack  of  pain  in  the  upper  part 
of  the  abdomen,  followed  by  a  temperature  of  102°.  The  jaundice 
did  not  vary. 

There  had  been  in  this  case,  therefore,  jaundice  of  fifteen 
months'  duration,  no  variation  in  the  depth  of  colour,  and  evi- 
dent enlargement  of  the  gall-bladder.  The  duration  of  the 
disease  and  the  absence  of  pronounced  wasting  prompted  me 
to  suggest  that  the  common  duct  was  probably  full  of  stones, 
and  the  exploration,  at  least,  was  desirable.  On  opening  the 
abdomen,  I  found  an  old  hydrops  of  the  gall-bladder,  probably 
of  longer  standing  than  the  jaundice,  and  a  complete  impaction 
of  the  common  and  hepatic  ducts  by  calcuU  and  sand.  There 
were  thirty-six  large  stones  in  the  common  duct,  all  consisting 
of  bilirubin  calcium,  and  the  intervals  between  them  were  filled 
up  with  a  thick,  tenacious,  black  mortar.  The  unvarying 
nature  of  the  jaundice  was  at  once  explained.  There  had  been 
a  most  effective  barrier  of  masonry  in  the  duct,  and  no  drop  of 
bile  had  been  able  to  pass  it. 

Case  3. — Stone  in  the  cystic  duct  pressing  upon  the  portal  vein 
and  the  common  bile-duct. — Patient  was  a  woman,  aged  fifty- 
nine.  Her  illness  began  suddenly  six  years  ago  with  violent 
pain  in  right  hypochondrium.  The  attack  was  one  of  typical 
gall-stone  colic,  and  was  followed  by  jaundice.  She  had  another 
attack  two  years  ago,  and  a  third  one  year  ago,  but  apparently 
was  not  jaundiced.  Two  months  ago  her  abdomen  began  to 
swell,  and  she  became  jaundiced.  One  month  ago  she  was  tapped 
and  11  pints  of  dark  fluid  drawn  off.  On  examination,  there 
was   marked   jaundice    with    much    ascites.     The   gall-bladder 


208 


COURVOISIER'S  LAW. 


formed  a  mobile,  rounded  tumour,  palpable  opposite  the  tenth 
costal  cartilage.  Nine  and  a  half  pints  of  dark  bilious  fluid 
were  drawn  from  the  peritoneal  cavity,  but  the  abdomen  rapidly 
refilled,  and  the  patient  died  two  days  later. 

Post-mortem. — Abdomen  distended  with  about  6  pints  of 
bloody  fluid  and  clot.  Gall-bladder  sausage-shaped,  43^  inches 
long  and  2  inches  broad,  containing  multitude  of  minute  stones 
in  clear  mucus.  Hepatic  ducts  markedly  dilated.  Half  stone 
size  of  a  medium-sized  Barcelona  nut.  Common  bile-duct 
dilated;  contained  a  few  minute  stones.  The  stone  in  the 
cystic  duct  pressed  against  the  common  duct,  almost  occluding 
it,  the  duct  being  dilated  above  the  point  of  pressure.  The 
stone  also  pressed  upon  the  portal  vein,  there  being  a  few  ad- 
hesions between  the  cystic  duct  and  the  peritoneum  over  the 
portal  vein.  Both  the  common  duct  and  portal  vein  were 
patent  to  the  passage  of  a  probe. 

Cases  similar  to  the  above  are  related  by  M'Arthur^  and 
Moore. 

Case  4. — Chronic  pancreatitis;  persistent  jaundice;  distension 
of  the  gall-bladder. — (The  case  now  quoted  is  only  one  of  several 
that  I  have  seen  illustrating  the  same  points.)  A  lady,  aged 
forty-five,  had  suffered  for  twenty  years  from  bihary  coHc. 
Seven  years  ago  she  became  jaundiced,  and  has  never  been  free 
from  it  since,  though  the  colour  has  varied  from  time  to  time. 
During  the  last  twelve  months  the  tinge  has  got  steadily  deeper, 
and  an  enlargement  of  the  gall-bladder  has  been  observed. 
There  has  been  a  loss  of  2  stones  in  last  three  months.  Opera- 
tion, March,  1904.  The  distended  gall-bladder,  almost  thrice 
its  natural  size,  was  full  of  black,  muddy  material  and  bile.  The 
common  duct  was  dilated;  it  contained  no  stone,  but  much 
gritty  material  similar  to  that  in  the  gall-bladder;  the  head  of 
the  pancreas  was  very  greatly  enlarged.  The  gall-bladder  was 
emptied  and  drained  for  five  weeks.  The  contents  of  the  com- 
mon duct  were  milked  backwards  into  the  gall-bladder.  In 
March,  1906,  the  patient  wrote  to  say  she  was  quite  well. 

14  209 


COURVOISIER'S  LAW. 


Case  5. — Deep  jaundice;  distension  of  the  gall-bladder  and  bile- 
ducts  by  hydatid  cysts. — The  patient,  a  woman,  aged  fifty-one, 
was  admitted  to  the  infirmary  with  a  history  of  chronic  unvary- 
ing jaundice,  distension  of  the  gall-bladder,  and  enlargement  of 
the  liver,  of  five  months'  duration.  Within  a  few  days  death 
occurred  from  acute  mania.  The  patient  was  almost  moribund 
when  admitted,  and  a  diagnosis  of  mahgnant  disease  of  the  head 
of  the  pancreas  was  made;  no  operation  was  possible  on  account 
of  the  patient's  desperate  state.  At  the  post-mortem,  a  large 
hydatid  cyst  was  found  in  the  right  lobe  of  the  fiver;  it  com- 
municated with  the  gall-bladder.  The  gall-bladder,  cystic 
and  common  ducts  were  as  full  as  they  could  possibly  be  of  small, 
grape-fike  hydatid  cysts. 

Group  2. — Cases  of  chronic  obstructive  jaundice, 
without  distension  of  the  gall-bladder,  due  to  malignant 
disease. 

Case  6. — Mrs.  A.,  aged  fifty-seven,  seen  February,  1905. 
For  several  years  there  had  been  attacks  of  ''spasms";  the  last 
attack  was  more  than  five  years  ago.  In  several  of  the  attacks 
there  was  jaundice:  on  one  occasion  jaundice  persisted  for  five 
months,  during  which  she  had  many  attacks  of  shivering  and 
pain.  After  an  exceptionally  bad  attack,  she  obtained  rehef 
from  the  jaundice,  which  had  never  returned  until  eleven  weeks 
before  I  saw  her.  The  present  attack  commenced  gradually, 
with  slight  pain  in  the  upper  part  of  the  abdomen.  The  jaundice 
gradually  deepened,  until  the  skin  became  a  dark  yellowish- 
green  in  colour.  Wasting  was  rapid  and  extreme;  in  eleven 
weeks  she  had  become  very  emaciated.  There  was  occasionally 
a  slight  elevation  of  temperature;  no  rigors  occurred,  and  the 
jaundice  never  lessened.  The  liver  was  slightly  enlarged  and 
readily  palpable;  the  gall-bladder  could  not  be  felt,  but  there 
was  tenderness  along  the  lower  border  of  the  liver.  This  was 
the  history  I  obtained  when  I  saw  her  in  February,  1905.     I 

210 


COURVOISIER'S  LAW 


expressed  an  opinion  that  there  was  probably  malignant  disease 
in  the  common  bile-duct  or  in  the  head  of  the  pancreas,  and  that 
the  absence  of  distension  of  the  gall-bladder  was  due  to  the  old 
attacks  of  cholecj'stitis.  Three  days  after  I  first  saw  her  a  rigor 
occurred,  followed  wdthin  a  week  by  a  second  one.  This  seemed 
to  make  exploration  desirable.  On  opening  the  abdomen,  I 
found  and  removed  a  mass  of  cancer  at  the  beginning  of  the 
common  duct.  The  gall-bladder  was  shrivelled,  and  its  con- 
tracted ca\'ity  contained  a  little  muddy  mucous  fluid.  The 
patient  died  in  a  few  hours. 

This  is  the  type  of  case  in  which  one  would  expect 
to  find  a  violation  of  Courvoisier's  law.  For  it  is 
probable  that  in  cases  of  carcinoma  of  the  common 
bile-duct,  as  in  carcinoma  of  the  gall-bladder,  the  de- 
velopment of  the  malignant  change  is  secondary  to 
prolonged  gall-stone  irritation.  The  inflammatory 
conditions  set  up  by  the  gall-stones  in  the  gall-bladder 
result  in  its  conversion  into  a  shapeless  mass  of  fibrous 
tissue,  incapable  of  distension. 

Case  7. — Chronic  obstructive  jaundice  due  to  malignant  disease 
of  the  head  of  the  pancreas;  no  distension  of  the  gall-bladder. — • 
The  patient  was  a  man,  aged  seventy-three,  who  had  suffered 
from  stomach  trouble  "all  his  life."  He  was  a  querulous  neu- 
rotic indi\ddual.  Three  and  a  half  months  before  I  saw  him 
he  had  become  jaundiced,  gradually  and  painlessly.  Wasting 
soon  became  pronounced,  and  vomiting  almost  continuous. 
There  was  no  fullness  of  the  gall-bladder.  A  mass  was  palpable 
just  above  the  umbilicus  and  a  little  to  the  right;  the  stomach 
was  dilated,  and  waves  of  contraction  were  seen  to  pass  con- 
stantly over  it.  The  patient  had  been  seized  a  few  hours  before 
I  saw  him  with  acute  pain  and  collapse.     A  diagnosis  of  perfora- 

211 


COURVOISIER'S  LAW. 


tion  of  a  malignant  growth  in  the  stomach  was  made,  and  I  saw 
him  to  advise  upon  the  question  of  operative  treatment,  and 
expressed  a  decided  opinion  against  any  such  measure.  The 
patient  died  a  few  hours  after  I  saw  him.  At  the  post-mortem 
a  large  internal  haemorrhage  was  found,  the  origin  of  which 
could  not  be  discovered.  There  was  malignant  disease  of  the 
head  of  the  pancreas.  The  gall-bladder  was  free  from  adhesions 
or  obvious  disease,  and  was  of  normal  size. 


Other  illustrative  cases  could  be  quoted,  but  evidence 
enough  has  been  adduced  to  show  that  Courvoisier's 
law,  like  all  other  laws,  is  capable  of  infraction. 

The  following  may  be  stated  as  the  chief  circum- 
stances in  which  the  law  may  be  violated: 

1.  Where  there  is  a  stone  or  a  stricture  in  the  cystic 
duct  causing  hydrops  or  empyema,  together  with  the 
acute  impaction  of  a  stone  in  the  common  duct. 

2.  Where  there  is  a  stone  in  the  cystic  duct  pressing 
upon  the  common  duct. 

3.  Where  there  is  distension  of  the  gall-bladder  by 
an  acute  inflammatory  process,  with  obstruction  of  the 
common  duct  by  stone. 

4.  Where  there  is  chronic  induration  of  the  head  of 
the  pancreas,  with  a  stone  in  the  common  duct. 

5.  Where  there  is  malignant  disease  of  the  common 
duct  at  any  part  of  its  course,  or  cancer  of  the  head  of 
the  pancreas,  and  a  chronic  sclerosing  cholecystitis. 

After  making  full  allowance  for  all  these  conditions, 

212 


COURVOISIER'S  LAW. 


it  cannot  be  denied  that  the  vahdity  of  the  law  is  es- 
tabUshed  in  at  least  90  per  cent,  of  the  cases  met  with 
in  practice.  In  the  remaining  10  per  cent,  there  is 
rarely  a  difficulty  in  diagnosis  when  the  other  symptoms 
are  passed  in  review. 

REFERENCES. 

1.  Beitrage  zur  Path,  und  Chir.  der  Gallenwege,  S.  58. 

2.  Bull,  et  m6m.  Soc.  de  chir.  de  Paris,  1900,  p.  1045. 

3.  Ann.  Surg.,  Phila.,  vol.  xxxv,  p.  666. 


213 


The  Mimicry  of  Malignant  Disease  in 
the  Large  Intestine.* 

Within  the  last  three  years  I  have  operated  upon  six 
cases  of  disease  of  the  large  intestine  under  the  mis- 
taken impression  that  I  was  dealing  with  examples  of 
malignant  disease.  In  all,  the  clinical  manifestations 
and  the  macroscopic  appearances  supported  my 
opinion,  but  minute  examination  of  the  specimens 
removed  or  the  subsequent  clinical  history  of  the  case 
has  proved  that,  in  all,  the  condition  was  of  a  non- 
malignant  character. 

It  is  well  known  that  tubercular  disease,  especially 
when  affecting  the  caecum  or  the  ascending  colon,  may 
produce  symptoms  and  signs  which  are  with  diflSculty 
distinguished  from  those  due  to  cancer.  I  have  twice 
performed  colectomy  for  supposed  carcinoma,  remov- 
ing the  csecum  and  a  part  of  the  ascending  colon  in  one 
case,  and  the  csecum,  ascending  colon,  and  a  part  of 
the  transverse  colon  in  another,  when  an  examination 
of  the  tumour  removed  displayed  the  undoubted  evi- 

*  Reprinted   from  vol.  xl  of   the  Clinical  Society's  Transac- 
tions, 1906. 

215 


MIMICRY  OF  MALIGNANT  DISEASE. 

dences  of  tubercular  disease.  But  such  cases  are  not 
very  uncommon,  and  it  is  not  with  them  that  I  propose 
to  deal  in  this  paper. 

It  is  not,  however,  so  well  recognised  that  tumours  of 
the  large  intestine,  of  the  sigmoid  flexure  more  es- 
pecially, may  present  all  the  characteristic  signs  and 
sj^mptoms  of  malignant  disease,  and  yet  prove  to  be 
nothing  more  than  simple  inflammatory  conditions. 
The  six  cases  whose  details  are  given  differ  in  character 
very  considerably;  the  one  circumstance  common  to 
them  all  is  the  close  resemblance,  indeed,  the  identity, 
of  the  symptoms  and  signs  with  those  of  malignant 
disease.     The  following  are  the  notes: 

Case  1. — A.  C,  aged  twenty-eight,  admitted  into  the  Leeds 
General  Infirmary  on  April  2,  1904,  complaining  of  passing 
blood  in  the  motions  and  of  frequent  and  irregular  action  of  the 
bowels. 

History. — The  present  illness  commenced  three  months  ago. 
Her  life  has  been  medically  uneventful  save  for  pneumonia 
seven  years  ago.  There  was  no  history  and  no  evidence  either 
of  syphilis  or  of  tubercle.  Aperients  were  occasionally  neces- 
sary; otherwise  the  bowels  were  regular  in  their  action  until 
the  present  illness.  Blood  was  first  noticed  in  the  stools  in 
the  early  part  of  January,  1904.  It  rapidly  increased  in  amount 
and  the  bowels  acted  five  or  six  times  a  day,  each  motion  con- 
taining more  or  less  blood.  As  much  as  haK  a  pint  of  mixed 
blood  and  mucus  was  passed  at  a  time.  In  consequence  she 
became  very  weak  and  had  to  take  to  bed.  About  two  months 
ago  she  began  to  vomit  frequently,  almost  all  food  being  rejected. 
This  subsided  for  a  time,  but  recommenced  a  fortnight  later 

216 


MIMICRY  OF  MALIGNANT  DISEASE. 


and  persisted  irregularly  up  to  admission.  The  passage  of 
blood  meanwhile  continued  and  became  rather  worse.  The 
bowels  acted  seven  or  eight  times  a  day,  the  stools  consisting 
principally  of  blood  and  mucus.  Occasionally  clots  were  passed. 
During  the  few  weeks  previous  to  admission  she  experienced  a 
good  deal  of  aching  pain  in  the  left  iliac  fossa,  which  continued 
to  within  a  short  time  of  her  coming  into  the  hospital. 

On  admission  she  was  obviously  much  reduced  and  very 
weak  and  bloodless  from  the  continued  haemorrhage.  She 
vomited  once  or  twice  on  the  two  days  following  admission. 
There  was  no  complaint  of  pain,  but  the  bowels  acted  from  five 
to  seven  times  a  day,  a  considerable  quantity  of  blood  and  some 
mucus  being  passed.  The  abdomen  was  distended  and  the 
intestine  obviously  obstructed. 

On  rectal  examination  the  sphincter  was  lax;  a  soft,  somewhat 
irregular  mass  was  to  be  felt  involving  the  whole  of  the  rectal 
wall.  Anteriorly  it  appeared  to  protrude  somewhat,  but  else- 
where felt  Hke  thick  moss  growing  on  the  wall  of  the  intestine. 
Its  upper  Hmit  could  not  be  reached.  The  rectum  from  about 
two  inches  above  the  anus  was  narrowed  to  such  a  degree  as  to 
make  the  passage  up  of  the  finger  very  difficult.  There  was 
slight  bleeding  as  a  result  of  the  examination. 

A  diagnosis  of  a  rapidly  growing  carcinoma,  with  partial 
obstruction,  was  made,  and  on  April  17,  1904,  inguinal  colotomy 
was  performed.  After  the  gut  was  opened  the  bowels  acted  at 
first  very  copiously,  afterwards  from  one  to  three  times  a  day. 
Some  blood-stained  discharge  continued  from  the  rectum, 
but  this  was  less  in  quantity  than  before.  Her  general  health 
improved  considerably  for  a  time.  The  discharge,  however, 
began  to  increase  and  both  blood  and  clots  were  passed.  There 
was  also  considerable  pain  in  the  sacral  region. 

On  June  16th  she  was  readmitted  after  having  been  at  home 
six  weeks.  The  colotomy  was  then  acting  two  to  three  times  a 
da3^  With  the  faeces  a  httle  blood-stained  mucus  was  passed. 
The  rectal  condition  was  apparently  much  the  same  as  on  the 
occasion  of  the  previous  examination.     The  patient  was  seen 

217 


MIMICRY  OF  MALIGNANT  DISEASE. 

by  Mr.  Ward,  under  whose  care  she  had  been  admitted,  and 
resection  of  the  growth  was  deemed  advisable. 

Operation. — On  June  30,  1904,  proctectomy  was  performed. 
The  patient  having  been  anaesthetised  in  the  ordinary  dorsal 
position,  the  colotomy  opening  was  plugged  with  gauze.  An 
incision  was  then  made  from  it  downwards  and  inwards  for 
about  3  inches.  The  peritoneum  having  been  divided,  the 
sigmoid  was  withdrawn  and  divided  between  clamps  about  ^ 
of  an  inch  below  the  artificial  anus.  The  lower  end  of  the 
upper  portion  was  then  closed  with  a  continuous  suture  of 
Pagenstecher  thread.  The  upper  end  of  the  lower  part  of  the 
sigmoid,  having  been  sterilised  by  the  cautery,  was  wrapped  in 
gauze.  The  patient  was  now  put  up  in  the  Trendelenburg 
position.  Clamps  were  then  applied  to  the  meso-rectum  close 
to  the  sacrum,  and  this  fold  was  divided  with  the  scissors  close 
to  the  clamps.  This  proceeding  was  repeated  lower  and  lower 
down  until  the  whole  of  the  upper  part  of  the  rectum,  together 
with  the  meso-rectum  and  its  contained  glands,  was  freed. 
The  peritoneum  of  the  pelvic  floor  was  then  snipped  through 
with  scissors  at  the  bottom  of  Douglas's  pouch,  and  by  means 
of  the  finger  this  opening  was  enlarged  and  the  rectum  down 
to  the  levator  ani  freed.  The  clamps  having  been  Hgatured  off, 
the  whole  of  the  gut  thus  detached  was  wrapped  in  gauze  and 
packed  into  the  pelvis.     The  abdominal  wound  was  then  closed. 

The  patient  was  next  placed  in  the  prone  position  with  the 
thighs  flexed  over  the  end  of  the  table,  the  knees  being  supported 
on  a  stool.  An  incision  was  made  in  the  middle  Hne  from  the 
centre  of  the  sacrum  to  the  anus,  bifurcating  anteriorly  to 
encircle  that  orifice.  The  last  sacral  vertebra  and  coccyx  were 
removed  and  the  lower  part  of  the  rectum  dissected  free,  as  in 
the  usual  operation  of  proctectomy.  There  was  very  httle 
bleeding  in  this  part  of  the  operation,  and  the  upper  gauze- 
enwrapped  part  of  the  gut  was  soon  reached  and  pulled  down. 
The  removal  was  completed  by  dissecting  away  the  anal  canal 
and  orifice,  the  lower  part  of  the  gut  not  being  opened.  The 
pelvic  floor  was  restored  as  far  as  possible  with  catgut  sutures 

218 


MIMICRY  OF  MALIGNANT  DISEASE. 


and  the  wound  closed,  large  gauze  drains  being  inserted,  anteriorly 
and  along  the  sacrum.  The  operation  lasted  nearly  an  hour 
and  a  half. 

The  patient  stood  the  operation  fairly  well.  The  gauze 
in  the  colotomy  opening  was  left  in  three  or  four  days,  but  the 
abdominal  wound  was  infected  from  it,  and  some  superficial 
suppuration  occurred.  It  was,  however,  completely  healed 
within  three  weeks  of  the  operation,  as  also  was  the  sacral 
wound.     Recovery  was  otherwise  uneventful. 

The  patient  is  now  (October,  1906)  perfectly  well.  She 
has  gained  weight,  so  that  she  is  now  heavier  than  she  has  ever 
been,  and  her  appearance  is  that  of  a  healthy,  well-nourished 
woman. 

Description  of  the  part  removed. — The  specimen  after  hard- 
ening in  formahn  measures  9  inches  in  length.  The  mucous 
membrane  is  greatly  thickened,  and  its  surface  is  raised  up  into 
prominent  fleshy  folds  and  convolutions.  Over  a  part  of  the 
specimen  there  is  a  considerable  degree  of  ulceration,  which, 
by  a  process  of  undermining,  has  resulted  in  the  formation  of 
bridges  and  overhanging  flaps  and  festoons  of  thickened  mucous 
membrane.  The  thickness  of  the  walls  varies  greatly,  some  of 
the  tuberous  projections  of  mucous  membrane  having  a  di- 
ameter of  nearly  3/2  an  inch;  these  projections  are  separated 
from  one  another  by  branching  sulci  in  such  a  manner  as  to  give 
to  the  surface  of  the  mucous  membrane  over  the  upper  one-third 
of  the  specimen  an  appearance  somewhat  resembling  the  cerebral 
cortex.  In  the  lower  part  of  the  specimen  ulceration  has  re- 
duced the  thickness  of  the  mucosa  in  places  to  1  or  2  milHmeters. 
The  muscular  coat  averages  about  2  millimeters  in  thickness, 
while  external  to  this,  in  the  lower  part  of  the  colon,  is  a  layer 
of  fat,  f  of  an  mch  thick.  All  the  outer  coats  of  the  bowel 
are  densely  thickened  and  fibrous,  and  the  lumen  of  the  gut 
here  is  probably  only  about  one-third  of  the  normal.  The 
inner  surface  of  the  bowel  does  not  present  any  definite  isolated 
tumour  or  polypoid  growth,  but  there  appears  to  be  a  general 
thickening  of  the  mucosal  rugae,  the  tags  of  mucous  membrane 

219 


MIMICRY  OF  MALIGNANT  DISEASE. 


in  the  lower  part  of  the  specimen  being  detached  at  one  extremity 
by  ulceration. 

Microscopic  examination  shows  an  overgrowth  of  the  mucous 
glands.  The  glands  are  of  irregular  form  and  separated  from 
one  another  by  dense  accumulations  of  lymphoid  cells.  Be- 
tween the  basis  of  the  glands  many  smaller  glands  are  seen  cut 
in  transverse  section;  these,  as  a  rule,  present  a  very  small 
lumen.  Sections  through  an  ulcerated  patch  show  much  the 
same  appearances  about  the  bases  of  the  gland  where  these  are 
not  disintegrated.  Here  there  is  more  infiltration  of  the  sub- 
mucosa  with  round  cells. 

This  condition  is  one  quite  unlike  anything  I  have 
met  with  before.  As  far  as  I  am  aware  no  similar 
manifestations  have  been  previously  described,  and 
the  disease  lacks  a  name.  It  is  certainly  not  syphilitic, 
nor  is  it  tuberculous.  Of  malignancy  there  is  no  sus- 
picion. The  only  specimen  in  any  degree  resembling 
this  that  I  have  been  able  to  discover  in  a  search 
through  the  literature  is  figured  by  Koch.^ 

Case  2. — Perforative  sigmoiditis;  localised  abscess. — Mrs.  H., 
aged  fifty-eight,  seen  in  consultation  with  Dr.  Norman  Porritt, 
Huddersfield.  The  history  was  that  the  patient  had  always 
enjoyed  exceptionally  good  health  up  to  six  years  ago,  when 
after  eating  some  tinned  chicken  and  ham  she  had  ptomaine 
poisoning  and  was  ill  two  months.  Four  years  ago  the  patient 
had  a  severe  illness,  with  much  pain  in  the  left  iliac  region. 
The  doctor  who  attended  her  at  that  time  told  her  she  had  "just 
escaped  peritonitis."  In  this  attack  she  was  confined  to  bed  for 
six  weeks.  Since  then  she  had  suffered  from  time  to  time  from 
attacks  of  pain  in  the  left  iliac  region,  many  of  which  have  kept 
her  confined  to  bed  for  a  few  days. 

220 


MIMICRY  OF  MALIGNANT  DISEASE. 

In  November,  1904,  what  proved  to  be  a  severe  illness  began 
with  acute  pain  across  the  abdomen;  this  was  followed  by  con- 
stipation, sickness,  and  abdominal  distension.  In  spite  of 
treatment  by  enemata,  etc.,  the  condition  of  obstruction  grew 
worse,  and  on  December  4,  1904,  I  opened  the  abdomen.  There 
was  considerable  distension  of  all  the  intestines,  and  peritonitis, 
with  serous  effusion.  The  seat  of  the  trouble  was  found  to  be 
in  the  sigmoid  flexure,  a  Uttle  above  the  brim  of  the  pelvis. 
The  bowel  here  for  about  3  inches  was  thickened,  swollen,  and 
very  hard.  A  perforation  was  found  on  the  upper  side,  and  a 
very  copious  deposit  of  lymph  was  plastered  over  and  around 
this.  The  condition  was  thought  to  be  one  of  mahgnant  disease 
of  the  sigmoid  flexure,  with  a  perforation  of  a  deep  ulcer  in  the 
growth.  A  large  tube  was  passed  down  to  the  open  ulcer  and 
the  rest  of  the  abdomen  closed.  The  patient's  condition,  to  my 
surprise,  gradually  improved;  but  on  December  20,  1904,  a 
deep-seated  mass  between  the  median  incision  and  the  left  iliac 
crest  was  found.  The  patient's  temperature  rose  and  a  second 
operation  was  performed,  some  pus  being  evacuated  from  an 
incision  two  inches  to  the  left  of  the  former  one.  The  abscess 
cavity  reached  to  the  sigmoid  flexure.  The  pus-collection  was 
clearly  the  result  of  insufficient  drainage  at  the  time  of  the  original 
operation.     The  subsequent  progress  was  good. 

Dr.  Norman  Porritt  kindly  saw  the  patient  on  October  1, 
1906,  and  reported:  "The  patient  did  well  and  is  now  better 
than  she  has  been  for  years.  All  the  discomfort  in  the  left  iliac 
region  which  was  more  or  less  always  present  after  the  ptomaine 
poisoning  has  entirely  left  her,  and  the  bowels,  which  never 
acted  without  medicine,  are  now  spontaneously  regular." 


The  condition  in  this  case  has  become  clearer  to  me 
since  I  operated  upon  one  of  the  cases  related  below. 
I  think  there  can  be  little  doubt  that  there  was  a 


221 


MIMICRY  OF  MALIGNANT  DISP:ASE. 

perforation   of   a   false    diverticulum    of  the  sigmoid 
flexure. 

The  appearance  and  the  consistence  of  the  tumour  of 
the  sigmoid  flexure  were  such  that  we  felt  no  doubt  that 
malignant  disease  was  present.  The  tumour  resembled 
in  all  particulars  that  which  I  removed  from  Case  5, 
recorded  below. 


Case  3. — Pericolitis  transversa;  colectomy. — Mrs.  W.,  aged 
fifty,  was  seen  in  consultation,  with  Dr.  Carlton  Oldfield  and  Dr. 
Greenwood  in  May,  1905.  She  had  suffered  for  some  months 
from  occasional  sickness  and  indigestion.  During  the  few  weeks 
preceding  my  examination  of  her  she  had  noticed  great  irregu- 
larity of  the  bowels.  Constipation  had  been  most  obstinate; 
when  relieved  by  an  aperient  there  was  diarrhoea  for  twenty- 
four  or  forty-eight  hours,  followed  again  by  constipation  for 
several  days.  The  patient  was  a  very  stout  woman,  but  had 
lost  nearly  two  stones  in  six  months.  On  examining  her  abdomen 
a  hard  mass  was  felt  situated  to  the  left  of  the  umbilicus.  This 
mass  was  about  four  inches  in  diameter,  and  apparently  adherent 
to  the  parietes.  A  diagnosis  of  a  carcinoma  of  the  transverse 
colon  was  made,  and  operation  advised. 

Operation  (May  31,  1905). — On  opening  the  abdomen  the 
peritoneum  was  found  to  be  indurated  and  gristly,  about  3-^  an 
inch  in  thickness.  Involving  the  transverse  colon  and  the 
adjacent  omentum  was  a  very  hard,  flat,  irregular  mass.  The 
induration  infiltrated  the  bowel  and  the  omentum  very  widely. 
No  enlarged  glands  were  perceptible.  No  doubt  whatever  was 
felt  by  any  of  us  that  the  mass  was  a  malignant  growth  in  the 
colon.  The  whole  tumour,  with  about  5  inches  of  the  transverse 
colon,  was  removed,  and  an  end-to-end  anastomosis  performed. 

When  the  intestine  was  laid  open,  it  was  found  to  be  firmly 
embraced  and  not  a  little  constricted  by  a  densely  hard  "scirrhus" 

222 


MIMICRY  OF  MALIGNANT  DISEASE. 

mass.  The  most  careful  examination  of  the  mucosa  revealed 
no  surface  defect;  the  membrane  was  everywhere  smooth  and 
supple;  there  was  no  ulceration  and  no  diverticula  could  be 
discovered.  Beneath  the  mucosa,  which  was  freely  movable 
on  the  deeper  structures,  was  a  wide  infiltrating  stratum  of 
fibrous  tissue  which  involved  all  the  other  coats  of  the  intestine, 
and  spread  into  the  omentum. 

Microscopically  the  mass  surrounding  the  gut  is  seen  to 
consist  of  dense  fibrous  tissue,  containing  here  and  there  small 
aggi"egations  of  Ij^mphocytes,  particularly  around  the  vessels. 
The  mucous  membrane  is  normal. 

The  origin  of  the  inflammatory  process  in  this  case 
was  not  discovered.  It  would  appear  to  have  been 
an  inflammation  of  the  peritoneum  surrounding  the 
transverse  colon,  with  an  implication  of  the  contiguous 
omentum.  No  affection  of  the  appendices  epiploicse 
was  found.  A  condition  of  things  exactly  similar  to 
this  is  known  to  occur  in  the  sigmoid  flexure.^ 

Case  4. — Growth  in  rectum;  proctectomy. — Mrs.  S.,  aged 
forty-one,  seen  with  Dr.  Waddington,  Bradford.  She  gave  a 
history  of  having  suffered  from  diarrhoea  for  five  months,  small 
quantities  of  mucus  at  times  tinged  with  blood  being  passed, 
sometimes  as  often  as  twenty  times  in  a  day.  The  rectum  on 
examination  was  felt  to  be  filled  with  a  very  soft,  friable,  ulcerat- 
ing mass,  fairly  movable,  though  extensive. 

On  July  17,  1905,  a  preliminary  inguinal  colotomy  was  per- 
formed, and  a  month  later  the  removal  of  the  growth  was  under- 
taken. Eleven  hours  before  the  second  operation  27  c.c.  of  a 
2  per  cent,  solution  of  nucleic  acid  were  injected  subcutaneously. 
At  the  commencement  of  the  operation,  at  9  a.  m.,  the  tempera- 
tm^e  was  100.4°  F.,  pulse  120.  The  pelvic  colon  and  rectum 
down  to  within  an  inch  or  two  of  the  anus  was  removed  by  the 

223 


MIMICRY  OF  MALIGNANT  DISEASE. 

trans-sacral  route,  the  upper  portion  of  the  pelvic  colon  being 
fixed  in  the  upper  angle  of  the  wound.  At  2  p.  m.  the  tempera- 
ture was  100°  F.,  pulse  140;  at  10  p.  m.  temperature  98.6°  F., 
pulse  95. 

Macroscopic  appearance  of  specimen. — The  specimen  measures 
14  inches  in  length  and  includes  portions  of  the  rectum  and 
pelvic  colon.  The  upper  8  inches  of  the  bowel  are  normal, 
but  below  this  the  mucous  membrane  is  covered  with  an  ex- 
uberant cauliflower-Uke  growth.  At  the  junction  of  the  healthy 
with  the  affected  portion  the  mucous  membrane  is  undermined; 
below  this  is  a  flattened  area  which  appears  to  be  superficially- 
ulcerated;  adherent  to  it  in  places  are  tags  of  villous  growth. 
The  lowest  portion  of  the  bowel,  extending  to  within  an  inch  of 
the  bottom  of  the  specimen,  is  occupied  by  a  soft  and  friable, 
projecting,  papillomatous  mass  which  is  extensively  undermined, 
forming  a  kind  of  bridge  over  a  portion  of  the  bowel.  The  whole 
circumference  of  the  intestine  is  involved  for  a  length  of  about 
4  inches.  The  obstruction  to  the  bowel,  partly  by  the  exuberant 
growth,  partly  by  a  thick  fibrous  deposit  in  the  wall  of  the  intes- 
tine, is  well  marked. 

Microscopic  report. — Sections  of  the  villous  growth  show 
dehcate  branching  processes  composed  of  a  framework  of  fine 
connective  tissue  and  covered  with  a  single  layer  of  tall  columnar 
cells  whose  nuclei  are  larger  and  stand  more  irregularly  at 
different  levels  than  those  of  the  cells  covering  the  non-viUous 
mucosa.  Sections  of  the  flattened  areas  of  mucous  membranes 
show  the  bases  of  the  intestinal  glands  strictly  hmited  by  the 
muscularis  mucosae;  but  more  superficially  the  ceUs  are  des- 
quamating and  lie  in  many  places  entangled  in  a  mucoid  sub- 
stance around  the  broken-down  gland  mouths.  The  lymphatic 
glands  examined  contained  no  epithehal  deposits.  In  the  ma- 
jority of  the  sections  there  is  no  evidence  of  mahgnancy,  but  in 
one  place  sections  show  irregularly  massed  epithehal  cells  extend- 
ing deeply  towards,  but  not  invading,  the  muscular  coat. 

The  clinical  history,  and  the  conditions  found  on 

224 


MIMICRY  OF  MALIGNANT  DISEASE. 

examination,  both  justified  a  diagnosis  of  malignant 
disease  in  this  case.  Yet  the  condition  is  a  simple  one. 
There  are  multiple  exuberant  papillomatous  growths 
undermined  by  ulceration,  and  a  considerable  thicken- 
ing of  the  outer  coat  of  the  bowel  due  to  a  deposit  of 
fibrous  tissue  has  caused  a  moderate  degree  of  stenosis. 

Case  5. — False  diverticula  of  sigmoid;  sigmoiditis;  colectomy. 
— Mr.  A.,  aged  fifty-two,  seen  with  Dr.  Helm,  of  Carlisle,  April 
2,  1906.  He  has  suffered  from  stomach  troubles  for  a  long  time, 
but  dates  his  present  illness  from  eighteen  months  ago.  He 
has  attacks  of  pain  in  the  abdomen  which  come  on  at  varying 
times  after  food,  from  half  an  hour  to  three  or  four  hours.  He 
also  suffers  from  a  sense  of  weight  and  distension  in  the  stomach, 
and  frequently  vomits.  He  vomited  blood  on  one  occasion 
twelve  months  ago.  The  bowels  are  habitually  constipated. 
During  the  last  few  months  this  has  been  a  more  serious  incon- 
venience than  before.  On  a  few  occasions,  constipation  has  per- 
sisted for  three  to  six  days,  and  has  given  way  only  to  persistent 
effort.  On  two  occasions,  five  weeks  ago  and  ten  days  ago, 
there  was  intestinal  obstruction.  The  abdomen  became  greatly 
distended,  obstruction  was  complete,  and  vomiting  of  intestinal 
contents  occurred.  The  last  attack  was  so  serious  that  it  was 
feared  operation  might  have  to  be  undertaken  for  a  possible 
growth  in  the  large  intestine. 

On  his  admission  to  the  Nursing  Home  the  stomach  was 
found  to  be  slightly  dilated;  no  contractions  were  seen  and  no 
tumour  felt.  The  gastric  contents  on  admission  to  the  Nursing 
Home  showed  the  presence  of  free  HCl  and  contained  sarcinse. 
After  a  twelve  hours'  fast  the  stomach  contained  some  food 
residue,  yeast,  and  sarcinse,  but  no  HCl  or  lactic  acid.  One 
hour  after  a  test-meal  HCl  was  present  in  excess.  There  was  a 
moderate  digestion-leucocytosis  one  hour  after  a  meal. 

Examination  per  rectum  revealed  nothing.     The  diagnosis 

15  225 


MIMICRY  OF  INIALIGNANT  DISEASE. 

was  chronic  duodenal  ulcer  with  stenosis.  A  fear  was  enter- 
tained that  there  might  also  be  a  growth  in  the  large  intestine, 
though  nothing  could  be  felt. 

At  the  operation,  on  April  4,  1906,  an  inflammatory  mass 
was  felt  in  the  duodenum.  It  was  hard  and  fibrous,  of  the 
size  of  a  walnut;  there  was  evident  duodenal  obstruction. 
The  large  intestine  was  then  examined  from  the  transverse 
colon,  which  was  distended  a  little  downwards.  On  reaching 
the  ilio-pelvic  colon,  a  hard  mass  was  felt  which  was  thought 
to  be  malignant.  As  this  was  deemed  the  more  important 
condition,  the  duodenal  ulcer  was  left  untreated  and  a  fresh 
incision  made  over  the  tumour,  which  was  very  adherent  to 
neighbouring  coils  of  small  intestine  and  to  the  abdominal 
wall.  The  adhesions  were  separated  and  the  tumour  delivered 
into  the  wound.  The  affected  part  of  the  sigmoid  flexure, 
in  length  about  5  inches,  was  excised  and  axial  anastomosis 
performed.  The  patient  recovered,  convalescence  being  some- 
what delayed  by  infection  of  the  upper  wound,  which  was  sutured 
last.  On  October  14,  1906,  the  patient  reported  that  he  had 
"made  very  great  progress."  The  following  is  the  report 
upon  the  specimen: 

"Macroscopic  appearances. — The  portion  of  the  bowel  re- 
moved is  about  5  inches  long;  the  walls  are  greatly  thickened, 
making  the  unopened  specimen  appear  to  be  involved  in  a 
growth.  The  external  surface  of  the  gut  is  reddened,  lumpy, 
and  in  places  flakes  of  lymph  mark  the  site  of  recent  adhesions 
to  neighbouring  coils  of  small  intestine.  On  la3dng  open  the 
bowel,  the  mucosa  shows  no  sign  of  growth  or  ulceration,  though 
its  lumen  is  shghtly  contracted  by  reason  of  the  induration  of 
the  gut.  This,  in  certain  parts,  is  over  13^  inches  in  thickness, 
the  increase  being  due  to  inflammatory  exudation  beneath  the 
peritoneum.  When  the  mucous  surface  is  examined  more  closely, 
numerous  pockets  or  diverticula  are  seen,  some  of  which  might 
contain  the  tip  of  a  No.  10  English  catheter.  On  cutting  sec- 
tions of  the  bowel  wall  parallel  with  the  long  axis  of  the  pockets 
these  are  found  to  be  of  variable  depth,  often  twisted  or  slightly 

226 


MIMICRY  OF  MALIGNANT  DISEASE. 

dilated  at  their  blind  extremities.  The  pouches  are  lined  by 
thinned  mucous  membrane  and  have  pushed  the  circular  muscle 
layer  before  them.  Around  the  tips  of  the  deeper  pockets  the 
muscular  coat  has  become  atrophied,  but  is  traceable  as  a  well- 
defined,  white,  fibrous-looking  layer  continuous  with  the  un- 
altered muscular  coat  elsewhere.  The  extremities  of  one  or 
two  pouches  are  surrounded  by  an  area  of  inflammatory  ex- 
travasation, though  no  perforation  can  be  actually  demonstrated. 
"Microscopically. — The  pockets  are  lined  by  normal  mucous 
membrane,  though  about  the  bases  of  the  gland-cells,  towards 
the  apex  of  the  pocket,  there  is  an  increased  number  of  small 
round  cells.  Immediately  beneath  the  glands  lies  the  muscularis 
mucosae;  this  can  be  clearly  traced  around  the  pouch.  External 
to  the  muscularis  mucosae,  and  separated  from  it  by  some  loose 
connective  tissue,  is  the  true  muscular  coat.  If  this  be  traced 
towards  the  extremity  of  the  pouch,  it  is  found  to  become 
thinned,  its  fibres  being  intermingled  with  fibrous  tissue  and 
interspersed  with  aggregations  of  lymphocytes.  Outside  this 
fibrous  layer,  which  covers  in  the  diverticulum,  the  wall  of  the 
gut  is  composed  of  loose  connective  tissue  containing  an  inflam- 
matory exudate  becoming  more  cellular  towards  the  peritoneal 
surface,  beneath  which  are  numerous  extravasations  of  blood. 
The  peritoneum  itself  is  covered  with  a  delicate  layer  of  fibrinous 
lymph,  in  the  meshes  of  which  are  entangled  numerous  lympho- 
cytes."* 

False  diverticula  of  the  large  intestine  are  of  great 
pathological  interest.  Acquired  diverticula  are  found 
in  all  parts  of  the  intestine,  from  the  duodenum  to  the 

*  Papers  dealing  with  this  subject  have  since  been  published 
by  Dr.  W.  J.  Mayo  (Surg.,  Gynaec.  and  Obstetrics,  1907,  v,  8) 
and  Dr.  Maxwell  Telling  (Lancet,  1908,  i,  843).  The  latter  con- 
tains the  most  complete  account  yet  published.  I  have  now 
had  eight  examples  of  this  condition. 

227 


MIMICRY  OF  MALIGNANT  DISEASE. 

rectum.  In  the  small  intestines,  though  numerous, 
their  clinical  significance  is  of  the  slightest,  for  the  thin 
fluid  contents  of  the  bowel  do  not  readily  become  pent 
up  in  these  little  pouches.  Gordinnier  and  Sampson^ 
say  that  they  have  been  unable  to  find  a  single  case 
reported  in  the  literature  in  which  clinical  symptoms 
have  arisen  from  diverticula  of  the  small  intestine. 
In  the  large  intestine  the  diverticula  are  not  infre- 
quently seen;  the  sigmoid  displays  them  more  fre- 
quently than  other  parts  of  the  colon.  The  false  di- 
verticula are  always  multiple;  they  are  hernial  pro- 
trusions of  the  mucosa  and  submucosa  along  a  track 
in  the  intestinal  wall  weakened  by  the  passage  of  a 
vessel.  Once  developed,  they  are  prone  to  become 
places  for  lodgment  of  the  solid,  slowly  traveling  in- 
testinal contents.  The  various  pathological  conditions 
resulting  from  acquired  diverticula  are: 

1.  Chronic  inflammatory  deposit  in  the  walls  of  the 
bowel,  producing  stenosis. 

2.  Localised  peritonitis  which  may  lead  to  the  for- 
mation of  pus. 

3.  General   suppurative   peritonitis,    the   result   of 
perforation. 

4.  Vesico-intestinal  fistulse,  due  to  rupture  of  a  local- 
ised abscess  into  the  bladder. 


228 


MIMICRY  OF  MALIGNANT  DISEASE. 


5.  Inflammation  and  thickening  and  contraction  of 
the  mesentery,  in  which  the  pouches  lie  (mesenteritis) . 

6.  Carcinoma.     Hochenegg  has  recorded  the  only 
case  of  cancer  developing  in  a  false  diverticulum. 

Case    Q.— Tumour   of  transverse    colon   and   splenic  flexure; 
ileo-sigmoidostomy.— Mrs.  W.  S.,  aged  sixty-two,  seen  with  Dr. 
Holderness,    December,    1903.     The    patient   has    suffered    for 
seven  months  from  flatulence,  coUc,  constipation,  and  loss  of 
weight.     During  the  last  three  months  she  has  twice  been  con- 
fined to  bed  for  periods  of  three  and  four  days  respectively  in 
attacks  of  subacute  intestinal  obstruction.     In  the  last  of  these 
I  saw  her,  and  on  examination  I  found  the  abdomen  distended; 
coils  of  small  intestine  were  seen  contracting,  and  the  caecum, 
ascending  and  transverse  colon  could  be  seen  to  distend  and  could 
be  felt  to  harden.     Loud  rumbhng  noises  were  heard  in  the 
abdomen,  and  the  patient  told  us  that  she  had  noticed  these 
"bubbhng"  sounds  for  several  weeks  past.     For  the  twenty- 
four  hours  before  I  saw  her  the  patient  had  been  very  nauseated 
and    had   vomited    twice.     The    general    condition   was    good. 
Shortly  after  my  visit  the  obstruction  yielded  to  a  gravitation 
enema,  the  bowels  being  copiously  relieved  on  several  occasions, 
and  the  abdomen  becoming  soft  and  flaccid  again.     A  diagnosis 
of  maUgnant  stricture  of  the  splenic  flexure  was  made,  and  the 
patient  came  to  a  nursing  home  for  operation.     On  her  arnval 
there  the  abdomen  was  hoUow,  the  wall  relaxed,  and  a  tumour 
could   be   distinctly   felt  in  front   of   the   left   kidney.     When 
grasped  between  the  hands  the  mass  felt  of  the  size  of  a  cocoanut. 
Operation  (December  14,   1903).— An  incision  was  made  in 
the  left  linea  semilunaris  and  the  abdomen  was  opened.     The 
transverse  colon  was  found  to   be  thickened  and  red;    the  de- 
scending colon   and  sigmoid  flexure  were  pallid   and   empty. 
A  large,  excessively  adherent  mass  was  seen  and  felt  occupymg 
the  left  end  of  the  transverse  colon.     The  mass  was  hard,  smooth, 
but  irregular  in  shape;   it  was  adherent  in  aU  directions  to  the 

229 


MIMICRY  OF  MALIGNANT  DISEASE. 

abdominal  wall,  the  stomach,  the  diaphragm,  and  to  a  few  coils 
of  intestine.  Resection  was  impossible,  and  I  had  to  be  content 
with  a  short-circuiting  operation.  I  secured  the  lowest  part 
of  the  ileum  and  united  it  to  the  sigmoid  flexure  (ileo-sigmoid- 
ostomy) .  The  distal  limb  of  the  ileum  was  narrowed  by  infolding 
sutures  of  linen  thread. 

The  recovery  of  the  patient  was  uneventful.  Since  the 
operation  she  has  gained  weight  steadily;  the  tumour  has 
entirely  disappeared;  nothing  can  be  felt  in  the  region  it  once 
occupied  so  fully.  The  bowels  act  well,  and  the  patient's  appear- 
ances justify  her  written  statement  that  she  "never  felt  better." 

In  this  case  I  had  no  suspicion  but  that  the  tumour 
was  carcinoma  in  a  stage  so  advanced  as  to  render 
resection  mechanically  impossible.  But  it  is  almost 
certain  that  I  was  mistaken,  and  that  the  tumour  was 
a  chronic  inflammatory  mass  involving  the  colon.  Its 
exact  origin  is  quite  uncertain. 

In  addition  to  these  cases  I  have  also  seen,  in  con- 
sultation with  Dr.  Henry  White,  of  Bradford,  a  patient, 
a  man  aged  sixty  (?),  upon  whom  colotomy  was  per- 
formed some  years  ago  by  one  of  the  most  distinguished 
of  living  surgeons,  for  intestinal  obstruction  due  to  a 
mass  in  the  lower  part  of  the  sigmoid  flexure  or  the 
upper  part  of  the  rectum — a  mass  which  was  supposed 
to  be  malignant  in  nature.  The  colotomy  acted  well, 
and  to  everyone's  surprise  the  tumour  gradually  melted 
away,  and  eventually  no  trace  of  it  could  be  discovered. 
The  colotomy  opening  was  then  closed.     Over  a  year 

230 


MIMICRY  OF  MALIGNANT  DISEASE. 

later  a  tumour  had  again  formed,  and  intestinal  diffi- 
culty was  so  great  that  the  re-opening  of  the  colotomy 
wound  was  under  consideration.  But  persistence  with 
enemata  relieved  the  obstruction,  and  the  bowels 
began  to  act  regularly  again.  The  tumour,  which  was 
still  perceptible,  gradually  disappeared,  and  for  the 
last  few  years  the  patient's  condition  has  been  per- 
fectly satisfactory. 

The  six  cases  here  recorded  have  only  afforded  four 
specimens,  but  each  of  these  is  of  considerable  interest. 
Of  the  three  other  cases  I  think  it  is  safe  to  say  that, 
in  the  first  two,  no  one  seeing  the  conditions  disclosed 
by  the  operations  would  have  hesitated  for  one  moment 
to  declare  that  the  tumours  were  carcinomatous.  In 
the  last  case  the  diagnosis  of  carcinoma  of  the  sigmoid 
flexure  was  made,  and  treatment  based  thereupon  was 
carried  out  by  an  acknowledged  expert.  Yet  the 
tumour  disappeared  completely,  reappeared,  and  has 
again  resolved. 

The  inflammatory  tumours  of  the  large  intestine, 
excluding  the  tuberculous  conditions,  are,  it  would 
appear,  far  more  frequent  than  we  have  supposed. 
The  exact  nature  of  the  conditions  present  are  not 
always  the  same.  The  inflammation  may  begin  in 
and  penetrate  the  mucosa;  a  false  diverticulum  may 
form  and  may  be  combined  with  a  form  of  polypoid 

231 


MIMICRY  OF  MALIGNANT  DISEASE. 

growth;  or,  finally,  the  inflammatory  deposit  may 
affect  the  peritoneal  coat,  chiefly  or  solely,  leaving  the 
mucosa  supple  and  intact. 

It  is  important  to  remember  that  the  naked-eye  ap- 
pearance of  the  tumours  in  many  of  the  cases  is  such 
that  the  mimicry  of  carcinoma  is  complete.  Unless 
a  careful  microscopic  examination  is  made,  differen- 
tiation is  impossible.  It  is  accordingly  not  unreason- 
able to  suppose  that  in  some,  at  least,  of  the  cases  of 
*'cure"  after  colectomy  for  carcinoma  an  error  has 
been  made  of  the  kind  to  which  I  have  drawn  attention. 

REFERENCES. 

1.  Archiv  f.  klin.  Chir.,  Bd.  Ixx,  1903,  p.  891. 

2.  See  "  Sigmoidites  et  Perisigmoidites,"  Saillant,  Paris,  1906. 

3.  Jour.  Amer.  Med.  Assoc,  vol.  i,  1906,  p.  1585. 


232 


The  Surgical  Treatment  of  Cancer  of 

the  Sigmoid  Flexure  and  Rectum, 

with  Especial  Reference  to  the 

Principles  to  be  Observed.* 

It  cannot  truthfully  be  said  that  the  surgical  treat- 
ment of  carcinoma,  occurring  in  the  upper  part  of  the 
rectum  or  in  the  sigmoid  flexure,  is  at  the  present  time 
entirely  satisfactory.  Two  reproaches  may  justly  be 
brought  against  it:  the  first,  that  removal  is  attended, 
in  no  small  proportion  of  cases,  either  by  regional  or  by 
distant  recurrence;  the  second,  that  colostomy  has  to 
be  performed,  on  account  of  the  sacrifice  of  a  large 
portion  of  the  bowel,  in  perhaps  a  majority  of  cases. 
The  position  at  the  moment  seems  to  be  this:  that  if 
only  so  much  of  the  bowel  is  removed  as  will  permit  of 
end-to-end  anastomosis,  an  adequate  excision  of  the 
parts,  intestine,  lymph-vessels,  glands,  and  the  tissues 
which  bear  them,  can  hardly  be  made;  whereas,  on 
the  other  hand,  if  these  parts  are  freely  removed,  the 
performance  of  colostomy  is  compulsory.     It  is  the 

*  Reprinted  from  Surgery,  Gynecology,  and  Obstetrics,  May, 
1908,  pp.  463-466. 

233 


SURGICAL  TREATMENT  OF  CANCER. 


purpose  of  this  paper  to  show  that  a  free  removal  of 
the  area  involved  is  possible,  and  that  with  certainty 
in  most  cases,  and  with  probability  in  all,  an  end-to-end 
approximation  of  the  bowel  is  easily  possible. 

It  is  the  first  essential  in  all  operations  concerned 
with  malignant  disease  that  the  removal  of  the  parts 
shall  be  free,  and  that  it  shall  follow  certain  lines.  In 
the  large  intestine  the  growth  itself  must  be  removed, 
a  length  of  bowel  on  each  side  of  the  growth,  the  lymph- 
vessels  which  drain  the  bowel,  the  glands  in  which 
those  vessels  end  (all  the  primary  glands,  that  is,  and 
as  many  of  the  secondary  as  are  accessible),  and  finally 
all  the  tissue  in  which  those  glands  and  vessels  lie. 
In  the  case  of  the  sigmoid  flexure,  and  of  the  upper  part 
of  the  rectum,  this  will  involve  a  removal  of  the  growth 
and  of  healthy  intestine  on  each  side  of  it,  and  the  ex- 
cision of  all  the  glands  which  lie  along  the  arteries  as 
far  up  as  the  inferior  mesenteric  artery  at  its  origin 
from  the  aorta.  At  the  point  where  this  vessel  arises 
a  lymphatic  gland  is  always  to  be  found;  it  lies  along 
the  artery  before  the  origin  of  the  left  colic  branch, 
and  is  the  highest  of  the  chain  which,  beginning  at  the 
intestine  (in  any  part),  extends  upwards  along  the 
sigmoid  superior  hemorrhoidal  arteries  to  the  inferior 
mesenteric  trunk.  Beyond  this  gland,  the  chain  is 
continued  into  the  glands  which  lie  along  the  aorta. 

234 


SURGICAL  TREATMENT  OF  CANCER. 


This  gland,  therefore,  which  lies  on  the  inferior  mesen- 
teric, close  to  its  origin,  must  be  removed,  and  all 
glands  which  lie  below  it,  if  the  necessary  conditions 
just  enumerated  are  to  be  fulfilled.     In  the  removal 
the  inferior  mesenteric  artery  may  have  to  be  ligatured, 
either  immediately  beyond  its  origin,  or  after  the  left 
colic  artery  has  been  given  off.     Probably  in  many 
cases  the  gland  can  be  stripped  down  from  the  vessel 
by  firm  wiping  with  gauze,  after  the  peritoneum  above 
it  and  on  each  side  has  been  lightly  divided.     In  two 
of  my  recent  cases  I  have,  however,  found  this  im- 
possible, and  the  artery  at  its  origin  has  therefore  been 
hgatured.     This,  for  reasons  presently  to  be  disclosed, 
is  not  of  the  importance  it  might  seem.     The  ligature 
on  the  artery  is  the  summit  of  a  wedge  of  material  to 
be  removed,  the  base  of  which  lies  at  the  intestine. 
The  length  of  intestine  which  has  to  be  excised  is  not 
a  point  to  be  specially  considered,  for  though  it  may 
seem  paradoxical,  it  is  nevertheless  true  that  the  more 
freely  the  gut  is  sacrificed,  the  less  likely  is  neurosis  to 
follow,  and  the  more  certain  is  the  end-to-end  anastomo- 
sis to  be  successfully  accomplished.     In  one  of  my  cases, 
143^  inches  of  the  intestine  were  removed  and  end-to- 
end  suture  easily  performed. 

The  two  points  of  chief  significance  in  the  operation 
as  I  wish  to  describe  it  are : 

235 


SURGICAL  TREATMENT  OF  CANCER. 

1.  The  mohilising  and  displacement  of  the  intestine: 
This  is  carried  out  by  making  an  incision  through  the 
peritoneum  at  the  outer  side  of  the  mesosigmoid,  at 
the  points  where  this  mesentery  springs  from  the  parie- 
tal peritoneum.  The  sigmoid  together  with  its  mes- 
entery is  then  stripped  up  from  the  iliac  fossa  towards 
the  aorta,  the  peritoneum  on  the  inner  side  of  the 
sigmoid  being  lifted  off  the  posterior  surface  of  the  ab- 
domen until  the  middle  line  is  reached.  This  stripping 
extends  well  upwards  and  downwards,  until  the  whole 
flexure  and  the  upper  part  of  the  rectum  are  attached 
only  by  a  leaf  of  peritoneum  on  the  inner  aspect.  At 
a  later  stage  of  the  operation,  the  descending  colon  and 
the  splenic  flexure  are  similarly  mobilised,  by  incising 
the  peritoneum  to  their  outer  side  and  above  the  flexure 
and  by  stripping  the  gut  inwards  to  the  middle  line. 
The  middle  and  left  colic  arteries  are  in  the  peritoneal 
fold,  which  now  forms,  as  it  were,  a  mesentery  for  the 
bowel.  The  result  of  this  freedom  of  the  intestine  is 
that  it  can  be  quite  readily  drawn  down  so  that  the 
descending  colon  reaches  well  into  the  pelvis,  and 
could,  if  there  were  need,  be  made  to  extend  to  the 
anus.  In  carrying  out  this  manoeuvre  the  transverse 
colon  also  may  be  loosened,  so  that  its  central  V-shaped 
dip  is  straightened.  The  splenic  flexure  is  normally, 
of  course,  fixed  high  up  on  the  left  side;  in  its  altered 

236 


SURGICAL  TREATMENT  OF  CANCER. 

position  it  is  made  to  descend  several  inches.  This 
procedure  has  to  be  performed  before  it  can  be  realised 
how  perfectly  simple  it  makes  this  displacement  or 
transplantation  (if  one  may  so  term  it)  of  the  intestine. 
The  result  of  it  is  that  the  bowel  is  rendered  so  free 
that  it  can  readily  be  placed  in  such  a  position  that  the 
end  of  the  descending  colon  can  be  brought  into  easy 
apposition  with  the  divided  rectum  and  union  then 
secured  by  suture;  and  the  vascular  supply  of  the 
parts  is  secured  by  the  preservation  of  the  vessels  in 
the  peritoneal  fold,  by  which  alone  the  mobilised  gut 
now  remains  attached. 

2.  The  condition  of  the  vascular  supply:  It  might 
perhaps  be  supposed  that  the  severance  of  the  inferior 
mesenteric  artery  would  deprive  a  large  part  of  the 
sigmoid  and  of  the  descending  colon  of  its  blood-supply. 
This,  however,  is  not  the  case.  If  the  middle  and  left 
colic  arteries  be  examined,  it  will  be  found  that  they 
anastomose  at  about  two  inches  from  the  intestine,  in 
a  vessel  which  runs  parallel  with  the  bowel;  from  this 
artery  straight  branches  pass  to  the  intestine.  That 
the  circulation  through  this  vessel  is  carried  on  quite 
freely  after  section  of  the  inferior  mesenteric  may 
readily  be  demonstrated  in  any  operation  by  loosening 
the  clamp  applied  at  the  upper  severed  end  of  the 
sigmoid  flexure;  free  haemorrhage  occurs  at  once.     An 

237 


SURGICAL  TREATMENT  OF  CANCER 

examination  of  the  vascular  supply  of  the  transverse 
and  descending  colons  and  the  sigmoid  shows  clearly 
enough  that  the  sacrifice  of  the  direct  supply  to  the 
left  colic  artery,  by  ligature  of  the  inferior  mesenteric, 
is  not  in  the  least  likely  to  interfere  with  the  easy 
transmission  of  blood  through  the  vascular  arch  which 
the  left  colic  makes  with  the  middle  colic  above  and 
with  the  sigmoid  and  superior  mesenteric  below.  The 
important  outcome  of  this  is  that  the  upper  divided  end 
of  the  sigmoid  flexure,  at  whatever  high  point  the 
division  is  made,  is  freely  supplied  with  blood,  even 
after  the  inferior  mesenteric  trunk  has  been  divided. 

These  two  points,  then,  make  it  clear  that  a  great 
length  of  the  bowel  may  be  sacrificed  and  the  normally 
fixed  parts  of  the  large  intestine  above  the  division  be 
rendered  so  mobile  that  their  transplantation  is  a 
matter  of  no  difficulty;  and,  further,  that  the  high 
division  of  the  inferior  mesenteric  artery,  made  neces- 
sary by  reason  of  its  close  relation  to  glands  which  it  is 
imperative  to  remove,  does  not  devascularise  the  upper 
end  of  the  bowel  which  is  to  be  engaged  in  an  end-to-end 
anastomosis. 

The  precise  details  of  the  operation  to  be  practised 
will  depend  upon  the  exact  position  the  growth  may 
occupy.     I  will  first  describe  the  procedure  necessary 


238 


SURGICAL  TREATMENT  OF  CANCER. 

in  a  case  of  gi'ovv'th  about  the  middle  of  the  sigmoid 
flexure. 

The  patient  is  placed  in  the  Trendelenburg  position 
and  a  long  incision  made  in  the  middle  line.  A  Doyen's 
valve-retractor  now,  or  a  little  later  in  the  operation, 
gives  a  good  exposure  of  the  pelvis.  The  intestines 
are  packed  away  with  swabs,  only  the  rectum,  sigmoid, 
and  a  part  of  the  descending  colon  being  at  first  visible. 
The  sigmoid  is  lifted  up  from  the  posterior  abdominal 
wall,  and  with  the  scalpel  or  scissors  an  incision  is  made 
in  the  peritoneum  of  the  iliac  fossa,  immediately  to  the 
outer  side  of  the  mesosigmoid.  This  incision  is  con- 
tinued down  into  the  true  pelvis,  keeping  close  to  the 
intestine,  and  up  along  the  outer  side  of  the  descending 
colon.  A  piece  of  gauze  wrapped  around  the  fingers 
now  strips  up  the  mesosigmoid  from  the  iliac  fossa,  and 
the  separation  is  continued  steadily  towards  the  middle 
line.  The  ureter  is  to  be  displayed  in  all  the  length  of 
the  incision,  so  that  its  security  is  in  no  doubt.  The 
spermatic  vessels  are  also  seen,  and  are  carefully 
handled,  to  avoid  damage  to  the  vein,  which  tears 
readily.  The  freeing  of  the  peritoneum  on  the  iimer 
side  of  the  sigmoid  and  the  descending  colon  is  con- 
tinued until  the  aorta  is  reached,  and  the  inferior  mesen- 
teric trunk  is  recognised  at  its  origin.  The  bowel  is 
now  quite  freely  movable  and  can  be  turned  well  over 

239 


SURGICAL  TREATMENT  OF  CANCER. 

to  the  right,  attached  by  a  single  leaf  only  of  the  peri- 
toneum in  which  the  vessels  lie.  This  peritoneal  leaf 
is  translucent;  by  holding  it  up  to  the  light  the  exact 
line  of  the  vessels  can  be  seen,  and  the  position  of  many 
of  the  glands  defined.  The  raising  of  the  peritoneum 
with  the  bowel  has  been  carried  out  in  such  manner  as 
to  leave  the  pelvic  wall  bare,  all  fat  and  glands  and 
vessels  are  raised  up  with  the  fold  of  the  serous  mem- 
brane. Into  the  space  made  bare  a  large,  hot,  moist 
swab  is  packed.  The  inferior  mesenteric  artery  is  now 
surrounded  by  an  aneurysm  needle  at  its  origin;  it  is 
tied  in  two  places  with  strong  catgut,  and  divided.* 
From  this  peritoneal  wound  two  incisions  are  made,  the 
one  upwards  towards  that  point  where  the  sigmoid 
flexure  or  descending  colon  is  to  be  divided,  the  other 
downwards  over  the  aorta  and  along  the  front  of  the 
sacrum  to  the  rectum  at  the  place  where  its  division  is 
necessary.  To  meet  the  lower  end  of  this  peritoneal 
incision  a  continuation  is  made  of  the  incision  already 
begun  on  the  outer  side  of  the  sigmoid.  The  two  meet 
across  the  front  of  the  rectum  or  the  lower  part  of  the 
sigmoid.  The  point  of  their  union  is  determined  by 
the  position  of  the  growth.  At  this  stage  all  that  is 
necessary  to  remove  the  wedge-shaped  area  to  be  sacri- 

*  If  no  gland  lies  on  the  vessel  before  it  gives  off  the  left  colic, 
the  ligature  may  be  applied  below  this  branch. 

240 


SURGICAL  TREATMENT  OF  CANCER. 

ficed  is  the  division  of  the  intestine  above  and  below. 
This  is  effected  between  clamps,  after  sedulous  care 
has  been  taken  to  avoid  infection.  The  liberated  mass 
is  then  removed.  It  may  be  10  inches  long  at  its  in- 
testinal base,  or  even  more.  The  free  vascularity  of 
the  upper  extremity  of  the  bowel  may  be  demonstrated 
by  a  slight  loosening  of  the  clamp.  The  approxima- 
tion of  the  two  ends  of  the  intestine  would  now  seem 
perhaps  to  be  almost  impossible,  but  the  mobilisation 
of  the  descending  colon  and  the  splenic  flexure  will  soon 
render  their  anastomosis  easy.  When,  however,  it 
seems  likely  that  this  displacement  of  the  descending 
colon  will  be  needed,  it  is  desirable  to  carry  it  out  before 
the  intestine  is  severed  so  as  to  be  certain  of  a  perfectly 
aseptic  operation  field  at  the  time.  The  end-to-end 
anastomosis  is  then  completed  in  the  usual  way. 

For  a  growth  in  the  rectum  the  same  principles  apply. 
The  highest  gland  in  the  lymphatic  chain,  that  which 
lies  on  the  inferior  mesenteric  artery,  must  be  taken 
away.  Nothing  less  will  do.  The  inferior  mesenteric 
artery  must  then  be  divided,  either  above  or  possibly 
beyond  the  origin  of  the  left  colic  artery.  The  peri- 
toneal incision  begins  to  the  left  of  the  upper  part  of  the 
rectum  and  the  sigmoid,  and  both  these  are  wiped  up- 
wards with  gauze  towards  the  aorta.  They  are  rend- 
ered mobile  before  anything  else  is  done.  The  in- 
16  241 


SURGICAL  TREATMENT  OF  CANCER. 

ferior  mesenteric  is  then  divided,  the  peritoneum  in- 
cised downwards  over  the  front  of  the  sacrum,  the 
middle  sacral  artery  ligatured,  and  the  sacral  hollow 
wiped  clean  by  repeated  applications  of  gauze,  stripping 
little  by  little.  When  this  has  been  done,  the  amount 
of  freedom  which  it  is  necessary  to  give  the  descending 
colon  must  be  ascertained,  and  be  provided.  End-to- 
end  anastomosis,  when  the  bowel  has  been  severed,  will 
not  always  be  possible  inside  the  abdomen,  for  probably 
only  four  or  five  inches  of  the  lower  part  of  the  rectum 
remain.  In  such  circumstances  the  upper  end  of  the 
rectum  is  tied  with  a  stout  catgut  ligature  before  divi- 
sion. After  the  removal  of  this  growth,  an  assistant 
passes  a  pair  of  forceps  into  the  dilated  anus  and  seizes 
this  tied  end  of  the  rectum,  which  is  then  inverted  until 
the  ligatured  end  can  be  made  to  protrude  beyond  the 
anus.  The  upper  divided  end  of  the  sigmoid  is  then 
pulled  through  the  anus  with  forceps  and  an  anastomo- 
sis made  by  MaunselFs  method.  Many  of  the  details 
of  this  procedure  are  the  same  as  those  laid  down  by 
C.  H.  Mayo.^  The  essential  differences  are,  that  in  the 
method  I  describe  the  bowel  above  is  freely  mobilised, 
so  that  easy  end-to-end  anastomosis  is  possible,  a 
greater  length  is  removed,  and  the  excision  of  the  entire 
glandular  group  is  ensured.  It  is  probably  safe  to 
say  that  this  last,  and  I  think  most  essential,  feature  of 

242 


SURGICAL  TREATMENT  OF  CANCER. 

the  operation  has  never  previously  been  suggested  or 
adopted  as  a  routine  procedure.  In  the  operations 
generally  practised  colostomy  is  performed  too  fre- 
quently. This  serious  drawback  to  the  cosmetic 
attributes  of  the  operation  can  be  avoided,  strange 
though  it  may  seem,  by  a  higher  division  of  the  ar- 
teries, and  by  a  wider  removal  of  the  intestine,  pro- 
vided the  principle  of  displacement  of  the  colon  be  duly 
observed. 

For  low  rectal  cancer  I  have  never  carried  out  an 
abdominal  operation,  but  if  adequate  measures  are  to 
be  taken  to  remove  the  invaded  area  in  accordance 
with  the  principles  laid  down,  no  other  course  than  this 
seems  rational.  Operations  which  merely  go  ''wide  of 
the  disease"  do  not  meet  the  necessities  of  the  case. 
We  have  not  yet  sufficiently  realised  that  the  surgery 
of  malignant  disease  is  not  the  surgery  of  organs:  it  is 
the  anatomy  of  the  lymphatic  system.  The  inherent 
futility  of  all  purely  sacral  operations  seems  to  me  to  be 
quite  evident.  If  it  is  true,  as  I  have  endeavoured  to 
show,  that  the  descending  colon  and  the  upper  part 
of  the  sigmoid  flexure  retain  their  vitality  after  the 
sacrifice  of  the  inferior  mesenteric  artery,  and  if  the 
mobilisation  of  the  colon  and  the  splenic  flexure  permit 
a  considerable  displacement  of  these  portions  of  the 
bowel,  then  in  all  cases  of  carcinoma  of  the  sigmoid 

243 


SURGICAL  TREATMENT  OF  CANCER. 


flexure  or  of  the  rectum,  whether  high  or  low  (the 
proctodseum  excepted),  an  abdominal  operation  seems 
desirable,  for  by  this  route  alone  can  the  whole  lym- 
phatic territory  be  extirpated.  The  observance  of  the 
practice  described  in  this  paper  should  do  much  to 
abolish  the  operation  of  colostomy  as  a  necessary  part 
of  the  radical  operation  for  cancer;  though  it  will,  of 
course,  always  be  demanded  for  those  cases  in  which 
obstruction  calls  urgently  for  relief. 

REFERENCE. 
1.  Surgery,  Gynecology,  and  Obstetrics,  1906,  iii,  240. 


244 


Index  of  Authors. 


ASHBY,  156 


Battle,  132 
Bernard,  186 
Biedl,  132 
Billroth,  71 
Blake,  79 
Bloch,  171 
Brenner,  162,  164 
Bunger,  126 


Cabot,  144,  145,  203 

Cammidge,  32,  67,  185,  186 

Cannon,  79 

Collinson,  81 

Courvoisier,  138,  140,  143,  144, 

145,  148,  149,  182,  201,  202, 

204,  205,  206 
CuUen,  51 
Cun^o,  58 


Daly,  59 

Delbet,  79 

Devic,  160,  162,  192 


Dobie,  85 
Doyen,  173 
Dreschfeld,  85 
Drysdale,  136 
Dunderdale,  187 


EcKLiN,  144,  203 
Erhardt,  131,  132 
Ewald,  18 


Fenger,   142,   146,   151,  204, 

205 
Fenwick,  51 


Gallavardin,  160,  162,  192 
Gilbert,  131 
Gordinnier,  228 
Greenwood,  222 


Haasler,  171 
Hahn,  134 
HaUy,  126 
Helm,  225 


245 


INDEX  OF  AUTHORS. 


Hey,  114 

Munro,  195 

Hochenegg,  229 

Murphy,  36,  64,  72 

Hoffman,  157 

Holderness,  229 

Nash,  33 
Nattan-Larrier,  127 

Janeway,  139 

Naunyn,  54,  55 

Johnson,  158 

Nicoladoni,  71 

Jordan,  164 

Nothnagel,  50 

Kehr,  154,  160,  164 
KeHing,  78 
Koch,  220 

,  173 

Oldfield,  222 
Opie,  67,  154 
Oxley,  156 

Kocher,  171 

Konitzky,  157 
Korte,  154,  156,  158 
Kraus,  52,  132 
Krokiewicz,  160 

,  160 

Pennato,  158 
Perry,  51 
Petersen,  73 
PhiUips,  158 
Porritt,  220,  221 

Lartigau,  67 
LetuUe,  127 

Porter,  134,  137 
Pye-Smith,  158 

Lipmann,  131 

RiEDEL,  31,  66,  154,  174 
Riegel,  18 

Malim,  59 

Mayo  (C.  H.),  16,  112,  242 

Robson  (Mayo),  31,  66,   194, 
203 

Mayo,  (W.  J.),  16,  : 

36,  57,  73, 

Rolleston,  155,  161,  162,  192 

74,  112,  164,  173, 

200,  227 

Rose,  137 

McArthur,  209 

Rostowzew,  157 

Merbach,  157 

Routier,  133,  135 

MoUoy,  54 

Mongourt,  150 

Moore,  209 

Sampson,  228 

Morison,  55,  169 

Seyffert,  157 

246 


INDEX  OF  AUTHORS. 


Shaw,  51 

Vautrin,  141 

Stewart  (Helen  G.),  186 

Von  Hacker,  73 

Stierlin,  134,  137 

Stokes,  163 

Stuart,  33 

Waddington,  223 

Swain,  156 

Walker,  186 

Ward,  218 

Wells  (Sir  Spencer),  36 

Telling,  227 

White,  14,  230 

Terrier,  201,  203 

Wolfler,  71,  72 

Thompson,  133 

Wright,  194 

Torrance,  69 

Wyeth,  157 

Treves,  157 

Tuffier,  79 

247 


Index. 


Abdomen,  diagnostic  explora- 
tion of,  60 
diseases       originating       in, 
knowledge  of,  11 
Abdominal  diseases,  inaugural 
symptoms  of,  41,  42 
knowledge  of,  11 
distension  in  rupture  of  com- 
mon duct,  135 
operation,  indications,    115 

mortality,  12 
wall,  resistance  of,  in  perfo- 
ration, 49 
Ampulla,  gall-stone  in,  opera- 
tion for,  172 
Ansemia  in  cancer  of  stomach, 

104 
Anamnesis,  value  of,  46 
Appendicitis,  64 
pain  in,  64,  65 
symptoms,  early,  64 
recognition,  44 
Appendix  dyspepsia,  86 

vermiformis,      diseases     of, 
post-mortem  in,  value,  16 
Ascites  in  obstructive  jaundice, 
184 


Ashton-under-Lyne  division  of 
British  Medical  Association, 
address  before,  11 


Ball-valve  in  common  duct 

from  stone,  142,  146 
Bile,  66,  67 

absorption  of,  after  rupture, 
131,  132 
Bile-duct,  common.     See  Com- 
mon bile-duct. 
Bile-ducts,  diseases  of,  26 

hydatid  cysts  of,  jaundice 
with,  210 
obUteration    of,    congenital, 
155 
Black  jaundice,  179 
Blood,  coagulation  of,  in  opera- 
tion for  obstructive  jaun- 
dice, 193 
in  stools  in  cancer,  63 
British    Medical    Association, 
Ashton-under-Lyne     Divi- 
sion, address  before,  11 


249 


INDEX. 


British    Medical    Association, 

Cancer  of  pancreas,  188 

surgical  section,  address  be- 

obstructive jaundice  from, 

fore,  177 

211 

stone  in  common  duct  and. 

differentiation,  190 

of  rectum,  operation  for,  233 

Cammidge's   pancreatic   reac- 

technic, 241 

tion,  67,  185 

of  sigmoid  flexure,  displace- 

Cancer,   obstructive    jaundice 

ment  of  intestine,  236 

from,  cases,  210 

mobiUzing  of  intestine, 

of  colon,   symptoms,   early, 

236 

61,62 

operation  for,  233 

treatment,  61,  62 

technic,  239 

of  common  duct,  160 

vascular    supply     and, 

case,  210 

237 

gall-stones  and,  160 

of  stomach,  44,  45 

infiltrating,  161 

anaemia  in,  104 

jaundice  in,  162 

anamnesis  in,  57,  95 

projecting,  161 

cases,  97,  98,  101 

symptoms,  162 

conclusions  regarding,  118 

treatment,  163 

diagnosis,  early,  95 

of  large  intestine,   mimicry 

diagnostic  exploration  in, 

of,  215 

60 

perforative    sigmoiditis 

dieting  in,  100 

mimicking,  220 

exploratory    incision    in, 

pericolitis       transversa 

114 

mimicking,  222 

first  class,  96 

rectal    growth   mimick- 

gastrectomy for,  56,  121, 

ing,  223 

122 

sigmoiditis     and     false 

gastric  contents  in,  analy- 

diverticula    mimick- 

sis, 117 

ing,  225 

groups  of  cases,  96,  118 

symptoms,  early,  61 

operation  in,  23,  24,  120 

treatment,  61 

early,  25 

tuberculosis  mimicking. 

gauze  stripping  method, 

215 

121 

250 


INDEX. 


Cancer  of   stomach,  operation 

Choledochostomy,  173 

in,  indications,  115 

Choledochotomy,  167 

prepyloric,  58,  59 

for  gall-stones,  167 

symptoms,  105 

for  obstructive  jaundice,  195, 

prevention,  108 

196 

pyloric,  58 

in  first  portion,  167 

symptoms,  105 

in  second  portion,  171 

radical  cure  of,  58 

in  third  portion,  172 

second  class,  99 

Kocher's,  172 

symptoms,  early,  58,  102 

McBurney's,  172 

early,   56,  95,  96,   109, 

retro-duodenal,  171 

110 

rotation  of  common  duct  in, 

third  class,  106 

170 

treatment,  early,  95 

trans-duodenal,  172 

ulcer    and,    22,    57,    107, 

Cholehthiasis,    26.      See    also 

108 

Gall-stone  disease. 

pancreatitis  and,  differentia- 

Coagulation   time    in    biliary 

tion,  32 

obstruction,  194 

tumour  of  colon  mimicking. 

Colectomy  in  cancer  of  intes- 

•    229 

tine,  61 

Catarrhal  jaundice,  66,  67 

Collapse  in  perforation,  48 

Cholangitis,     suppurative,     in 

Colon,   cancer  of,   symptoms. 

obstruction  of  common  duct, 

early,  61,  62 

154 

treatment,  61,  62 

Cholecystectomy,  nature's,  55 

transverse,  tumour  of,  mim- 

Cholecystenterostomy for  ob- 

icking cancer,  229 

structive  jaundice,  197 

Common  bile-duct,   anatomy. 

Cholecystostomy  for  obstruc- 

125 

tive  jaundice,  197 

cancer  of,  160.     See  also 

Choledochectomy,  173 

Cancer  of  common  duct. 

Choledocho-duodenal      fistula, 

micro-organisms  in,  131 

139 

obstruction  of,  140 

Choledocho-duodenostomy,  173 

acute,    140.      See    also 

obstructive  jaundice,  199 

Common  bile-duct,  ob- 

Choledocho-enterostomy, 174 

struction  oj,  complete. 

Choledochoplasty,  173 

ball-valve  in,  142,  146 

251 


INDEX. 


Common    bile-duct,    obstruc- 

Common    bile-duct,    obstruc- 

tion  of,   by   pressure   from 

tion  of,  incomplete,  itching 

without,  165 

in,  153 

by    stones,    choledoch- 

jaundice  in,  148,  152 

otomy  for,  167 

liver  in,  149,  153 

in  cystic  duct,  208 

pain  in,  147,  152 

by  stricture,  155.     See 

steeple  chart  in,  149, 

also  Stenosis  of  com- 

152 

mon  duct. 

symptoms,  147 

cancer  of  pancreas  and. 

temperature  in,   147, 

differentiation,  190 

148,  152 

cancerous,  160.  See  also 

urine  in,  150 

Cancer  of  common  duct. 

jaundice  in,  190 

chronic,  140.     See  also 

number  of  stones,  140 

Common  bile-duct,  ob- 

operation for,  selection 

struction    of,    incom- 

of  cases,  190 

plete. 
complete,  140,  141 

diagnosis,  143 

from  gall-bladder  dis- 
ease, 143 

from  within,  141 

from  without,  142 

gall-bladder  in,  143 

jaundice  in,  142,  152 

sclerosis  of  gall-blad- 
der in,  145 

symptoms,  142 
Courvoisier's   law,  144, 

201 
gall-bladder  in,  201 
incomplete,  140,  146 

cholangitis    in,    sup- 
purative, 154 

emaciation  in,  151 

fseces  in,  150 


pancreatitis  in,  154 
operations  on,  166 

general  technic,  166 
retro-duodenal  portion,  126 
rotation  of,  170 
rupture  of,  129.    See  also 
Rupture    of    common 
bile-dv^t. 

traumatic,    lymph    de- 
posit after,  130 
stenosis  of,  155.    See  also 

Stenosis  of  common  duct. 
stone  in,  28,  140 

pancreatitis  and,  31,  32 
stricture  of,  155.    See  also 

Stenosis  of  common  duct. 
supra-duodenal      portion, 

126 
surgery  of,  125 
termination  of,  127 


252 


INDEX. 


Common  bile-duct,  trans-duo- 

Duodenal   ulcer,   haemorrhage 

denal  portion,  126 

in,  50 

wide-mouthed  opening  of, 

hunger-pain  in,  21 

139 

operation  in,  24 

Courvoisier's  law,  144,  182 

pain  in,  20 

basis  of,  202 

perforation,    early   symp- 

violations of,  183,  201 

toms,  47 

Cystic  duct,  stone  in,  pressure 

gastro-enterostomy    in. 

on  portal  vein  and  common 

results,  83 

duct,  208 

symptoms,  18,  19,  20 

Cystico-duodenostomy  for  ob- 

early, 50 

structive  jaundice,  199 

recognition,  44 

Duodenum,  diseases  of,  16 

Dyspepsia,  appendix,  86 

gall-bladder,  54 

Derby   Medical  Society,   ad- 

dress before,  41 

Diabetes,  pancreatitis  and,  67 

Diverticula,  false,  of  intestines. 

Empyema  of  gall-bladder  from 

227 

stone   in    cystic   duct   with 

Duodenal  ulcer,  anamnesis  in, 

obstructive  jaundice,  207 

19 

Exploratory  incision  in  cancer 

attacks  in,  21 

of  stomach,  114 

cicatrix  of,  stenosis  of  com- 

mon duct  from,  159 

death  from,  frequency,  16 

diagnosis,  19 

F^CAL  movements  in  cancer, 

mistaken,  50 

62 

early  recognition,  45 

Faeces  in  obstructive  jaundice, 

food  as  rehef  in,  20,  21 

185 

frequency,  18,  19 

False  diverticula  and  sigmoidi- 

gastric ulcer  and,  differen- 

tis   mimicking    cancer, 

tiation,  19 

225 

gastro-enterostomy        in. 

of  intestines,  227 

mortality,  76 

Fistula,    choledocho-duodenal, 

results,  85 

139 

253 


INDEX. 


Fistula  from  rupture  of  com- 
mon duct,  139 
vesico-intestinal,  35 


Gall-bladder  disease,  26 

complete    obstruction    of 

common  duct  from,  143 

distension  and  jaundice  with 

pancreatitis,  209 
dyspepsia,  54 
empyema  of,  from  stone  in 

cystic    duct,    obstructive 

jaundice  with,  207 
hydatid    cysts   of,    jaundice 

with,  210 
hydrops  of,  obstructive  jaun- 
dice with,  208 
in  complete  obstruction  of 

common  duct,  143 
in  obstructive  jaundice,  182 
sclerosis  of,  in  cases  of  stone, 

145,  202 
stones  in,  absence  of  symp- 
toms, 54,  55 

inaugural  symptoms,  30 

nature  cure,  169 
Gall-stone  disease,  26 

anamnesis  in,  26,  27 

cancer   of   common   duct 
and,  160 

cardinal  symptom,  28 

chilUness  in,  53 

diagnosis,  27 

early  recognition,  45 


Gall-stone  disease,  frequency, 
15,  16 
inaugural  symptoms,  30 
indigestion  in,  27,  53 
jaundice  in,  26,  28 
nature  cure  of,  55 
pain  in,  27 
pancreatitis  and,   31,   32, 

66,  189 
prodromal  stage,  52 
stone    in    common    duct, 
140.     See  also  Common 
hile-duct. 
symptoms,  26 
absence  of,  54 
early,  51 
in    ampulla,    operation   for, 

172 
in  gall-bladder,  nature  cure, 

169 
post-mortems  and,  14 
Gastrectomy    in    cancer,    56, 

121,  122 
Gastric    contents    in    gastric 

ulcer,  117 
Gastro-enterostomy  and  after, 
71 
complications  after,  73 
conclusions  regarding,  92 
first,  71 

in  duodenal  ulcer,  mortality, 
76 
results,  85 
in  gastric  ulcer,  mortality,  77 

results,  85 
in  haemorrhage,  results,  84 


254 


INDEX. 


Gastro-enterostomy  in  hour- 
glass stomach,  results,  91 

in  perforating  ulcer,  results, 
S3 

indications,  23,  24 

jejunal,  72 

position  for  anastomosis, 
72-77 

mechanical  aids,  72 

mortality,  76,  81 
late,  89 

nature  of,  77 

no-loop,  73 

vomiting  after,  74,  76 

normal  position  of  jejunum 
in,  74 

passage  of  contents  through 
new  opening,  77 

peptic  ulcer  after,  80 

results,  77 
late,  77,  80 

success  of,  time  to  determine, 
82 

vertical,  76 

vomiting  after,  85 
Gauze    stripping    method    in 

operation  for  gastric  cancer, 

121 
Glycosuria  in  pancreatitis,  33 


HEMORRHAGE,  gastro-cnteros- 
tomy  in,  results,  84 
in  duodenal  ulcer,  50 


HaDmorrhage   in  duodenal  ul- 
cer, death  from,  16 
in  gastric  ulcer,  death  from, 

16 
in  obstructive  jaundice,  193 
in  prepyloric  cancer,  59 

Hepatico-duodenostomy  for 
obstructive  jaundice,  199 

Hour-glass  stomach,  gastro- 
enterostomy in,  results,  91 

Hunger-pain,  21 

Hydatid  cysts  of  gall-bladder 
and  bile-ducts,  jaundice 
with,  210 

Hydrops  of  gall-bladder,  ob- 
structive jaundice  with,  208 


Inaugural  symptoms,  41 
Indigestion  due  to  ulcer,  18 

in  gall-stone  disease,  27,  53 
Intestines,    diseases   of,    post- 
mortem findings,  value,  16 
large,  cancer  of.    See  Cancer 
of  large  intestine. 
diseases  of,  34 
false  diverticula  of,  227 
growths  of,  34 
small,   false   diverticula  of, 
228 
Islands  of  Langerhans  in  pan- 
creatitis, 67 
Itching  in  obstruction  of  com- 
mon duct,  153 
operation  for,  197 


255 


INDEX. 


Jaundice,  black,  179 

catarrhal,  66,  67 

hydatid  cysts  of  gall-bladder 
and  bile-ducts  with,  210 

in  cancer  of  common  duct, 
162 

in  complete  occlusion  of  com- 
mon duct,  142,  152 

in    gall-stone    disease,    26, 
28 

in  incomplete  obstruction  of 
common  duct,  148,  152 

in  traumatic  rupture  of  com- 
mon duct,  133,  134 

obstructive,  177 
ascites  in,  184 
Cammidge's  pancreatic  re- 
action in,  185 
cholecystenterostomy  for, 

197 
cholecystostomy  for,  197 
choledocho-duodenostomy 

for,  199 
choledochotomy  for,    195, 

196 
clinical  history,  178 
Courvoisier's  law  in,  182 
cystico-duodenostomy  for, 

199 
diagnosis,  178 
differential  diagnosis,  201 
etiology,  181 
faeces  in,  185 
from  cancer,  cases,  210 
gall-bladder  in,  182 
haemorrhage  in,  193 


Jaundice,    obstructive,  hepati- 
co-duodenostomy  for,  199 

hydrops    of     gall-bladder 
with,  208 

in  cancer  of  pancreas,  188 

in   occlusion   of   common 
duct,  190 

in  pancreatitis,  189 

itching  in,  153,  197 

liver  in,  184 

operations  for,  177,  193 
drainage,  193 
for  removal  of  obstruc- 
tion, 193,  195 
haemorrhage  in,  193 
selection  of  cases,  187 
^ort-circuiting,  193,196 

pancreas  in,  183 

pancreatitis  and  gall-blad- 
der distension  with,  209 

physical  signs,  182 

removal    of    obstruction, 
193,  195 

selection  of  cases,  177 

urine  in,  185 

with    empyema    of    gall- 
bladder, 207 

without  gall-bladder  dis- 
tension, cases  210 
Jejunal  gastro-enterostomy,  72 
Jejunum,  normal  position  of,  74 
peptic  ulcer  of,  80 


Kocher's 
172 


choledochotomy, 


25Q 


INDEX. 


Large    intestine,    cancer    of. 
See  Cancer  of  large  in- 
testine. 
diseases  of,  34 
false  diverticula  of,  227 
growth  of,  34 
Liver  in  obstructive  jaundice, 

149,  153,  184 
Lymp  deposit  after  rupture  of 
common  duct,  130 


McBurney's  choledochotomy, 
172 

Micro-organisms    in    common 

duct,  131 
Mucus  in  stools  in  cancer,  63 


No-loop    gastro-enterostomy, 
73 
vomiting  after,  74,  76 
Nottingham    Medico-chirurgi- 
cal  Society,  address  before, 
125 


Obstructive    jaundice,     177. 
See  also  Jaundice,  obstructive. 
Oddi's  sphincter,  127 


Pancreas,  cancer  of,  32,  188 
obstructive  jaundice  from, 
211 
17  257 


Pancreas,  cancer  of,  stone  in 
common  duct  and,  differ- 
entiation, 190 

diseases  of,  31 

post-mortem         findings, 

value,  16 
symptoms,  early,  66 

in  obstructive  jaundice,  183 

in  other  diseases,  67 
Pancreatic    duct,    termination 
of,  127,  128 

reaction,     Cammidge's,    67, 
185 
Pancreatitis,  31,  189 

cancer   and,   differentiation, 
32 

diabetes  and,  67 

gall-stone  disease  and,  31,  32, 
66,  189 

glycosuria  in,  33 

in    obstruction   of    common 
duct,  154 

islands  of  Langerhans  in,  67 

jaundice     and     gall-bladder 
distension  with,  209 

symptoms,  early,  66 

treatment,  198 
Pathology  of  hving,  11 
value,  12,  37,  38 

post-mortem,  value,  13 
Peptic  ulcer  of  jejunum,  80 
Perforation,  collapse  in,  48 

diagnosis,  49 

early  symptoms,  47 

gastro-enterostomy   for,    re- 
sults, 83 


INDEX. 


Perforation,  prevention,  48 
resistance  of  abdominal  wall 
in,  49 
Pericolitis  transversa  mimick- 
ing cancer,  222 
Peritonitis,  acute  diffuse,  47 
from    rupture    of    common 

duct,  139 
tuberculous,  35 
operation  for,  35 
removal  of  local  source  of 
infection,  37 
Post-mortem   findings,    value, 
13 
gall-stones  and,  14 
in  appendicial  diseases,  value, 

16 
in  gastric  diseases,  value,  16 
in  intestinal  diseases,  value, 

16 
in  pancreatic  disease,  value, 
16 
Prepyloric  cancer,  58,  59 

symptoms,  105 
Pyloric  cancer,  58 
symptoms,  105 
stenosis,    congenital    hyper- 
trophic, 157 


Rectal  growth  mimicking  can- 
cer, 222 
Rectum,  cancer  of,  operations 
for,  233 
technic,  241 


Retro-duodenal     choledochot- 
omy,  171 
portion  of  common  bile-duct, 
126 
Rontgen-ray   to  diagnose   in- 
testinal obstruction,  64 
Rotation  of  common  duct,  170 
Rupture  of  common  bile-duct, 
129 
pathologic,  138 
fistula  from,  139 
into  peritoneal  cavity, 
138,  139 
peritonitis  from,  139 
traumatic,  129 

abdominal  distension 

in,  135 
Courvoisier's      treat- 
ment, 138 
differential  diagnosis, 

136 
effects  of,  130 
emaciation  in,  136 
jaundice  in,  133,  134 
stools  in,  134,  135 
subcutaneous,  129 
symptoms,  133 
treatment,  136 


Sclerosis  of  gall-bladder  in 
gall-stone  disease,  145,  202 

Serum  injections  before  opera- 
tion for  biliary  obstruction, 
194,  195 


258 


INDEX. 


Short-circuiting  operations,  ef- 

Stomach tumour,  operation  for. 

fects,  77 

indications,  116 

Sigmoid    flexure,     cancer    of. 

ulcer,    cancer   and,    22,    57, 

See  Cancer  of  sigmoid  flexure. 

107,  108 

Sigmoiditis  and  false  divertic- 

diagnosis, 19 

ula  mimicking  cancer,  225 

duodenal  ulcer  and,  differ- 

perforative, mimicking  can- 

entiation, 19 

cer,  220 

frequency,  18 

Small  intestine,  false  diverti- 

of death  from,  16 

cula  of,  228 

gastro-enterostomy  in,  23, 

Spasm  in  intestinal  cancer,  63 

24 

Sphincter  of  Oddi,  127 

mortality,  77 

Splenic    flexure,    tumour  of. 

results,  85 

mimicking  cancer,  229 

operation  in,  23,  24 

Steeple  chart  in  obstruction  in 

indications,  115 

common  duct,  149 

perforation,    early   symp- 

Stenosis of  common  duct,  ac- 

toms, 47 

quired,  157 

gastro-enterostomy    in, 

cartilaginous,  158 

results,  83 

etiology,  157 

Stools  in  cancer,  62,  63 

from   duodenal    scar, 

in  traumatic  rupture  of  com- 

159 

mon  duct,  134,  135 

symptoms,  158 

Stricture  of  common  duct,  155. 

congenital,  155 

See  also  Stenosis  of  common 

hypertrophic,  157 

duct. 

symptoms,  156 

Supra-duodenal  portion  of  com- 

treatment, 156,  157 

mon  bile-duct,  126 

Stomach  cancer,  44,  45.     See 

Surgical    Section     of     British 

also  Cancer  of  stomach. 

Medical  Association,  address 

diseases,  17 

before,  177 

post-mortem          findings, 

value,  16 

hour-glass,      gastro-enteros- 

tomy  in,  results,  91 

Terrier's  law,  201 

stasis,  operations  for,  indica- 

Trans-duodenal   choledochot- 

tions,  116 

omy,  172 

259 


INDEX. 


Trans-duodenal  portion  of 
common  bile-duct,  126 

Transverse  colon,  tumour  of, 
mimicking  cancer,  229 

Tuberculosis  mimicking  cancer 
of  large  intestine,  215 

Tuberculous  peritonitis,  35. 
See  also  Peritonitis,  tubercu- 
lous. 


Ulcer,  duodenal,  16,  17. 

also  Duodenal  ulcer. 
indigestion  due  to,  18 


See 


Ulcer  of  stomach.  See  Stomach 
ulcer. 

peptic,  of  jejunum,  80 
Urine  in  obstructive  jaundice, 

185 
Urotropine  after  common  duct 

operations,  174 


Vesico-intestinal  fistula,  35 
Vomiting  after  gastro-enteros- 

tomy,  85 
after    no-loop    gastro-enter- 

ostomy,  74,  76 


260 


